Claim Shanahan, Jeremiah
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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 tPOlt supports your claim.
, '.
The Claim must be flied 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: J e.r (:lr\.\u...:VI S nQ V\ c~.\n Q "l
2. Address:J 7 5 Co L e0.., L'f\ < \~ l/'O'-flr~ )~ 5;< DO.;z
5Sd,-5873
(p/~d./O(P
/0: iq tAn-)
J-I-i//crcsf- Rei <4-JFk
,
3. Telephone Number:
4. Date of lricident:
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, give the
employee's name.) J1 b
I
Jt=
8. What were weather conditions like? C \-Pfl. (' S() n Yl~
9. Give name and address of any witnesses;~ P\
~ c... '\L s-\-
~
10. Did police investigate? (If so, give names of officers.)
C6.c:..,e ~ ()\ - 0(0- 0179)&
Yes )Johr'\ -\ \e~\
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
~o
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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.)
&Cl{Y'{JdV' .-tr; Du (Y,(x:'r Or) 6\CCf-/ TO';-jQK
C {A (Y\ I'J $ 7 L{ L{ ,,L-t 3
13. What other damages do you claim, if any?jJOn e
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?$ '1 L{ Lj .ll3
16. Why do you claim the City of Dubuque is responSible?]ne QCC \~('\\-
\ p()..S OUt- nS; ()\lj rOA-DoI CA~ --.:I G0~S sb~&-
aVl& \'fur enrQeLD p
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.) N D
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 0 5
day of ;:ru L 'I
,20~.
8(p~ ~~
. (Signature)
;:(erem.-c,t.'t ~iAaj.1dir.a;f
(Print Name)
(Rev. 1/00 & 7/01)
Driver Information Exchange Report
Dubuque Police Department
563-589.4410
U
N
I
T
001
Driver's Name - Last
TULLY
First
DEBT
Middle
JEAN
Suffix Date of Birth
Address
2188 ST JOHN DRIVE
City
DUBUQUE
State
IA
Zip
62002
Phone
(663) 557.8838 x
Gender
Female
Driver's License Number
' Class
B,M
State
IA
Endorsements Restrictions
_ PS NONE
Insurance Co. Name
IOWA COMMUNITIES
Insurance Co. Phone #
iNS (663) 589-4106 x
Owner Company Name
CITY OF DUBUQUE KEYLINE TRANSIT
Insurance Policy
#
Owner's Name- Last
' First
MkicRe
Suffix
{�
Address
60 W 13TH ST
1DUBUQUE
City
State
IA
Zip
52001- I
VIN No.
4RILJNTFA82R83GS52
Year
2002
Make
RTS
�62VN
Model
Style
I BUS
Vehicle Configuration
18
License Plate N
85988
Stale
IA
Year
2006
Most Damaged
01-Front
Area
Approximate Cost to Repair or Replace
U
I
T
002
Driver's Name - Last
SHANAHAN
First
JEREMIAH
Middle
WILLIAM
Sulfa
Date of Birth
Address
1756 LEA LANCE
City
DUBUQUE
Stale
IA
Iip
62002
Phone
(563) 682-6873 x
Gender Number
Male
Class
C
Slate
i IA
Endorsements
NONE
Restrictions
B
Insurance Co.
ACUITY
Name
Insurance Co. Phone 4
(808) 723-6441 x
Owner Company Name
Insurance Policy
N96298
#
Owners Name - Last
SHANAHAN
First
JEREMIAH
Middle
WILLIAM
Suffix
Address
1766 LEA LANE
City
DUBUQUE
State
IA
Zip
52002-
VIN No.
4T1BE32K14U334641
Year
2004
Make
TOYT
Model Style
CAM ; 40
Vehicle Configuration
License Plate tC
087AWP
State
IA
Year
2007
Most Damaged Area
Approximate Cost to Repair or Replace
County
Dubuque -31
Accident occurred within corporate limits of (city)
Dubuque -2100
Literal Description
0IJOHN F KENNEDY RD and HILLCREST RD and NO NAME ST
X-Coo dinete v-Coo Odin ate
00887231 104708582
If accident occurred outside of oily
limits show general vacinity: "NIA"
Direction
"N/A" of
Nearest City
"N/A"
Route (Cardinal)
Travel Direction "NIA"
On Road, Street, or Highway:
HILLCREST RD
At Intersection with:
"N/A"
Distance
30 Ft
Direction !Distance j Direction fMiiepost Number
3-E and J"NtA" "NA" of r"N!A" Or I
Definable intersection, bridge, or railroad crossing
JFK RD.
Officer
HEFEL, JOHN
Badge No.
41A
Law Enforcement Case Number
01-06-27608
Date of Accident
06/22/2008
Time of Accident
10:19 Hrs.
Printed At: Dubuque Police Department
Page 1 Form #:07-D6-27608
1982 ROCKDALE RD
DUBUQUE, IA 52003
PHONE: 563-583-9329
"y
-Urv-
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.-\--\ \
lP\?fl #
O}?~J
CD LOG NO 700-1
DATE 06/22/06
SHOP:
ADDRESS:
CITY STATE:
ZIP:
WILLIS AUTO BODY
1982 ROCKDALE RD.
DUBUQUE, IA
52003-
INSP DATE:
CONTACT:
PHONE 1:
FAX:
OWNER:
ADDRESS:
CITY STATE:
ZIP:
SHANAHAN, JERRY
1756 LEA LANE
DBQ, IA
52002
POINT OF IMPACT: 8
LIC#:
BODY COLOR: MARRON
CONDITION: EXCELLENT
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
UM=REMAN/REBUILT PRT
OE=REPLACE PXN OE SRPLS
TE=PARTL REPL PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
HOME PHONE:
06/22/06
MARK WILLIS
(563)583-9329
(563)583-9329
(563) 582-5873
DAYS TO REPAIR: 0
STATE: IA
VIN: 4TIBE32K14U334641
MILEAGE:
ACCTNG CTL#:
E=REPLACE OEM
UE=REPLACE OE SURPLUS
EU=REPLACE SALVAGE
PC=PXN RECONDITIONED
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI~R&I ASSEMBLY
RP=RELATED PRIOR
2004 TOYOTA CAMRY LE 4DOOR SEDAN
CODE: Y1743B/C OPTNS A/24BMCV
4CYL GASOLINE 2.4
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
DRIVER POWER SEAT
ALARM SYSTEM
OP GDE MC DESCRIPTION
NG=REPLACE NAGS
UC=RECONDITIONED PRT
EP~REPLACE PXN
PM=PXN REMAN/REBUILT
IT~PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P~CHECK
UP=UNRELATED PRIOR
TWO-STAGE - INTERIOR SURFACES
REMOTE KEYLESS ENTRY SYSTEM
U.S.A. BUILT VEHICLE
MFG. PART NO. PRICE AJ% BO HOURS R
'6
------------ ----- ----- -
52159AA903 229.04 1.6 1
REFINISH 3.7 4
52615AA050 53.13 0.3 1
REFINISH 0.5*4
ECONOt~Y PI',PT 3.00* 1
E 0566
L 0566 13
E 0567
L M15
EC M60
5 ITEMS
COVER,REAR BUMPER
COVER,REAR BUMPER
ABSORBER,REAR BUMPER
COLOR TINT
HAZARD. WSTE. REM.
?P.GE: 1
06/22/06
CD GnG "Nel 700-1
. .
MC MESSAGE (S)
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
OTHER PARTS
PAINT MATERIAL
PARTS & MATERIAL TOTAL
TAX ON PARTS @
7.000%
282.17
3.00
126.00
411.17
19.96
LABOR
I-SHEET METAL
2-MECH/ELEC
3-FRAME
4-REFINISH
5-PAINT MATERIAL
LABOR TOTAL
TAX ON LABOR
SUBLET REPAIRS
TOWING
STORAGE
RATE
48.00
50.00
52.00
48.00
30.00
REPLACE HRS
1.9
REPAIR HRS
91.20
4.2
201.60
@
7.000%
292.80
20.50
GROSS TOTAL 744.43
NET TOTAL 744.43
ADP SHOPLINK U9956 ES CD LOG 700-1 DATE 06/22/06 01:04:06PM R6.37 CD 06/06
HOST LOG
(C) 1998 - 2006 ADP CLAIMS SOLUTIONS GROUP, INC.
1.1 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
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PI'.GE 2
06/22/06