Claim Reiter, Gary & SusanCLAIM 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: Gary and Susan Reiter
2. Address: 1979 Asbury Rd.
3. Telephone Number: 557 1831
4. Date of Incident: 12/11/00
5. Time of Incident: 1:30-1:45 P.M.
6. Location of Incident (Be specific): On Loras Ave. Close to Alta Vista
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 of Dubuque Vehicle (snow plow / salt truck) passed my vehicle on the left clipping off driver's side mirror; vehicle did not stop
8. What were weather conditions like? Snow / streets slippery
9. Give name and address of any witnesses:
Abby Reiter, 1979 Asbury (passenger) , Sue Reiter (driver) 1979 Asbury, Joe Reichele, White St. (passenger)
10. Did police investigate? (If so, give names of officers.)
Case # 00-44764 Krapfl #53
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.)
See estimate attached -driver's side mirror clipped.
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?
$160.70 (see est. attached)
16. Why do you claim the City of Dubuque is responsible?
City truck responsible for damage
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 20th day of December , 2000.
/s/ Susan M. Reiter
(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 investigation is completed, a report and
reconunendation 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.
Address:
Telephone
Date of Incid~t
10.
11.
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.)
~at were weather conditions like? ~ ~ /
Did polie~ investigate? (If so. give nme~ of officers.)
Was anyone injured? (If so, give n~e, address and extent of
injuries. )
12. Was any damage done to property? (If so, describe property
and the extent of d~mage. Attach estimates of damages or
describe basis for ascertaining extent of damage.)
13.
14.
What other damages do you claim, if any?
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. )
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: ~/~
18o If the answer to Question 17 is yes, have yOU received
payment from that source, and if so, in what amount?
Dated at Dubuque, Iowa, this ~0~ day of
20CO
(Revi~ed January, 2000)
V(S~gnatuz/e)
(Print Name)
ACORD~ A~UTOMOBILE LOSS NOTICE
PHONE ~ NAIC CODE:
Yan~g im~u~nce & R~I Es~e
~86Cresc~t F~dge & Hi~y 20
I:~x=~, iowa s2003
POLICY NUMBER
REFERENCENUMBER
CAT#
CODE=/~/--~'~ IEUECO"E:~/ EXP TIO ATH EA~OEA E~AND?'ME [~AMI BEPONTSU
A,ENOY ~ f>~ ;X:~PMI IYEEI.'~NO
CUSTOMER ID:
INSURED CONTACT / ~ CONTACT IN~URED
POLICY INFORMATION
BODILY INJURY
LOSSPAYEE
~x~ I l U~EHE~ I I EXCES~ ICA.HIER=
INSURED VEHICLE
VEH# YEAH UAKE: ~)~,~,7"-//~'~'~
MEDICAL PAYMENT
(Check if
RELATION TO INSURED DATE OF BIRTH I DRIVER'S LICENSE NUMBER
(Employee, family, etc.)
DESCRIBE
DAMAGE
OTC DEDUCTIBLE
COLLISION DED
I (OuTMH~ E~RO, f CaO~ i~ ~ tRoAwiGnEg ~& etDc~DUcTIBLES
RESIDENCE PHONE
BUSINESS PHONE
RESIDENCE PHONE
PROPERTY DAMAGED
OTHER DRIVER'S
DESCRIBE
DAMAGE
I ESTIMATEAMOUNT WHERE CAN
DAMAGE
BE SEEN?
OTHER VEH/PROP INS? [ COMPANY OR
RESIDENCE PHONE
{~C, No):
BUSINESS PHONE
INJURED
NAME & ADDRESS
WITNESSES OR PASSENGERS
NAME & ADDRESS
PHONE(~C, No)
EXTENT OFINJURY
OTHER (Specify)
ad uster as~ gned
ACORD 2 (10/98)
NOTE: IMPORT.,a[N~TATE'~IFOR~TIO"/~" ~iE-~RSE S~ ~"
® A~:ORD CORPORATION 1988
Date: 12/t2/00 08:37 AM
Estimate ID: 1121
Estimate Version: 0
Preliminary
profile ID: Mitchell
Dan Kruse Pontiac, Nissan, BIVlW
600 Century Drive Dubuque, IA 52002
(3t6) 608-784S
Fax: (319) 583-7349
Damage Ass~=,~l By: Dave DeMoes
Deductible: UNKNOWN
Insured: GARY REITER
Address: 1979 ASBURY RD DUBUQUE, lA 52001
Telephone: Home Phone: (319) 067-1831
Mitchell Service: 917493
Description: 1990 Pontiac TransSport SE
Body Style: Van 112"WB
VIN: 1GMDU03E2WD273936
Drive Train:
3AL Inj 6 Cy! 2WD
Line Entry Labor Line item
item Number Type Operation Description
Part Type/
Part Number
Dollar Labor
Amount Units
I 700836 BDY REMOVE/REPLACE L FRT QQORPOWF-I~MIRROP~
2 700842 BDY REMOVE/INSTALL L FRT DOOR TRIM PANEL
10422028 GM PART
125.00 0.3 #
0A
# - Labor Note Applies
Labor Subtotals
Body
Labor Summary
Units Rate
0.7 38.00
Taxable Labor
Labor Tax
0.7
IlL Additional Costs
Total Additional Costs
Add'l
Labor Suble~
Amount Amount Totals
0.00 0.00 28.60 T
26.60
6.000 % 1,60
28.20
II. Part Replacement Summary
Taxable Parts
Sales Tax
Total Replacement Parts Amount
IV. Adjus~nents
Customer Responsibility
I. Total Labor:
8. Total Replacement Parts:
81. Total Additional Costs:
Gross Total:
6.000%
Amount
125.00
7.50
132.50
Amount
0.00
28.20
132.50
0.00
160]0
ESTIMATE RECALL NUMBER: 12/12/00 08:36:33 1121
UltraMate is a Trademark of Mitchell Intemstional
Mitchell Data Version: DEC_00_A Copyright (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.6.004 All Rights Reserved
Page I
of 2
Date: 12/12,~00 06:3;' AM
Estimate ID: 1121
Estimate Version: 0
Preliminary
Profile ID: Mitchell
IV. Total Adjustroents:
Net Total:
0.00
160.70
This is a preliminaw estimate.
Additional chanqes to the estimate may be required for the actual repair.
REPORT IS BASED ON OUR INSPECTION AND DOES NOT
~DDIONA.L PARTS OR LABOR WHICH MAY BE ~QU~P, ED AFTER
~-~wc~K%~AS BEEN OPENED UP THE INS,WILL BE NOTIFIED.
ESTIMATE RECALL NUMBER: 12/12/00 08:36:33 1121
Ult~aMate is a ~'J'Q~liml~ark of Mitcpx~J
Mitchell Data Ve;sion: DEC_00_A All Rights R~/
CopylJght (G) 1994.200~ M~)~G~lql~tional
UltraMate Version: 4.6.004
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