Claim, Germain, Matthew D.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: Matthew D. Germain
2. Address: 2324 Birchwood
3. Telephone Number: (319) 557 7742
4. Date of Incident: 12 21 2000
5. Time of Incident: Approx. 11:15 A.M.
6. Location of Incident (Be specific): Pennsylvania Ave. Westbound) between Rosemont intersection & Lucy intersection.
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.)
I - Matthew Germain) was traveling westbound on Pennsylvania, closest to the Center line and two city vehicles for snow removal were traveling eastbound at the same rate of speed. The snow thrower
shot snow over the dumpt truck and through my windshield.
8. What were weather conditions like? Clear & Cold
9. Give name and address of any witnesses: NA
10. Did police investigate? (If so, give names of officers.)
Yes
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
Yes, myself, cut on right hand.
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.)
Yes, my vehicle (90 Eagle Talon) received in upwards of $1600 in damages to windshield, roof and headlights.
13. What other damages do you claim, if any?
None at this time
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?
Repair of car (see estimate) and REntal Car while my car is getting fixed.
16. Why do you claim the City of Dubuque is responsible?
The City of Dubuque workes were at fault completely. The accident could not have been prevented.
They are responsible for all damages.
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 25th day of December , 2000.
/s/ Matthew D. Germain
(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
recommendation will be submitted to the City Council. You will be
provided with a copy of that report and recon~nendation.
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.
2. Address: 252ff rcb ovd
3. Telephone Number: ~/~ ~7~77q2_
4. Date of Incident: /2-SI -2000
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.)
9. Give name and address of any witnesses.
10.
11.
Did police investigate? (If so, give names of officerS.)
Was anyone injured? (If so, give n~une, aadres~nd extent of
injuries. )
12. 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 nature and address of
insurance company and amount paid. )
15.
16.
17.
What amount do. you claim from the City of Dubuque?
why do you claim the City of Dubuque is responsible?
Have you mad~ a~.y ~laim agaiDst anyone else for damages as a
result of this zncxdent? ~/~
d'
If. yes, .givs name an address:
18. If the answer to Question 17 is yes= have you received any
payment from that source, and if so, in what amou/lt?
Dated at Dubuque, Iowa, this
200~
(Revised January, 2000)
(Signature)
(Print Name)
Date: 12122/00 10:45 AM
Estimate ID: 2826
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Damage Assessed By:
LENNY VALENTINE & SONS, INC.
923 PERU RD DUBUQUE, IA 52001-8604
(3t9) 588-4689
Fax: (319) 588-4650
Tax ID: 42-1125448
TWO CONTINENTAL FRAME M~%CHINES
GENESIS II COMPUTERISED MEASURING SYSTEM
PRICE IS EASY TO BEAT/QUi~LIT¥ IS NOT
UNIBOD¥ SPECIALISTS
WAYNE VALENTINE
Deductible: UNKNOWN
Owner MATT GERMAIN
Address: t48 1/2 WEST 23RD DUBUQUE, IA 52001
Telephone: Home Phone: (319) 582-6889
Description: 1990 Eagle Talon TSi
Body Style: 2D Cpe
VlN: 4E3CT64USLE144583
Mitchell Service: 912426
Drive Train: 2.0L Turbo lnj 4 Cyt 5M 4WD
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Unite
I 202590 BDY REMOVE/REPLACE
2 900500 BDY* REPAIR
3 200014 GLS REMOVE/REPLACE
4 220850 BDY REMOVE/REPLACE
5 220900 BOY REMOVE/REPLACE
6 220920 BDY REMOVE/REPLACE
7 220920 BDY REMOVE/REPLACE
8 220920 BDY REMOVE/REPLACE
9 220940 BDY REMOVE/REPLACE
10 220940 BDY REMOVE/REPLACE
11 220940 BDY REMOVE/REPLACE
12 231190 BDY REPAIR
13 AUTO REF REFINISH
14 231380 BDY REMOVE/INSTALL
15 231550 BDY REMOVE/REPLACE
16 936001 ADD'L COST
17 AUTO REF ADD'L OPR
18 AUTO ADD'L COST
19 AUTO ADD'L COST
20 AUTO ADD'L COST
R SIGNAL LAMP ASSEMBLY
CLEAN INTERRIOR
W/SHIELD GLASS
UPR W/SHIELD MOULDING
R ROOF DRIP RAIL MOULDING
R W/SHIELD MOULDING INSERT
R W/SHIELD MOULDING I~NSERT
R WISHIELD MOULDING INSERT
R W/SHIELD PILLAR GR(~MMET
R W/SHIELD PILLAR GROMMET
R W/SHIELD PILLAR GROMMET
ROOF PANEL
ROOF PANEL '~
ROOF HEADLINER
FRT ROOF TRIM
TOWING
CLEAR COAT
PAINT/MATERIALS
SHOP MATERIALS
HAZARDOUS WASTE DISPOSAL
ESTIMATE RECALL NUMBER: 12/22/00 08:13:t7 2826
UltraMate is a Trademark of Mitchell International
Mitchell Date Version: DEC_00_A Copyright (C) t994 - 2000 Mitchell International
UltraMate Version: 4.6.004 AIl Rights Reserved
MB597764
Sublet
Sublet
MB479089
MB479088
MB479533
MB479533
MB479533
MD551717
MB551717
MB5517t7
Existing
Existing
MB828045
86.00 0.3 #
76.00' 0.0'
249.95* 0.0'#
t0.75 3.5 #
46.00 0.2
1.45
1.48
1.45
1.70
1.70
1.70
10.0'#
C 2.4
1.5'
21.00 0.2
t 35.00 *
1.0
81.60 *
25.00 *
2.55*
Page I of 2
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Data: 12122/00 10:45 AM
Estimate ID: 2826
Estimata Version: 0
Preliminary
Profile ID: Mitchell
L Labor Subtotals
Body
Refinish
Add'l
Labor Sublet
Units Rate Amount Amount Totals
t5.7 38.00 0.00 75.00 67J.60 T
3A 38.00 0.00 0.00 129.20 T
Taxable Labor 800.80
Labor Tax ~ 6.000 % 48.05
Labor Summary 19.1 8a~.85
IlL Additional Costs Amount
Taxable Costs 137.55
Sales Tax
Non-Taxable Costs t 06.60
Total Additional Costs 252.40
II.
Part Replacement Summary
Taxable Parts
Sales Tax ~
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
6.000%
Amount
423.15
25.39
448.54
Amount
0,00
I. Total Labor:
II. Total Replacement Parts:
Ill. Total Additional Costs:
Gross Total:
Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
848.85
448.54
252.40
1,549.79
0.00
1,549.79
ESTIMATE RECALL NUMBER: t2/22/00 08:t3:t7 2826
Ult~aMate is a Trademark of Mitchell Intarnational
Mitchell Data Version: DEC_00_A Copyright (C) 1994 - 2000 Mitchell Intarnafional
UltraMate Version: 4.6,004 All Rights Reserved
Page 2
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