Claim Metz, Kenneth M.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: Kenneth M. Metz
2. Address: 2303 Washington
3. Telephone Number: 563 583 0094
4. Date of Incident: 11 19 01
5. Time of Incident: 2:00 P.M.
6. Location of Incident (Be specific): Rear Fire Headquarters Parking Lot
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.)
Fire Dept. Vehicle hit rear of my truck moving it ahead into Parking Meter Post riven by Chief Dan Brown.
8. What were weather conditions like?
Clear and sunny
9. Give name and address of any witnesses:
Capt. Jay Imhoff (James), 4935 Asbury Cr.)
10. Did police investigate? (If so, give names of officers.) Yes, Dan Sabers
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
None
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.)
Front and Rear Damage to 1990 Dodge Pickup
See Attached Repair Est.
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?
$2,429.75
16. Why do you claim the City of Dubuque is responsible?
Dub. Fire Dept. Vehicle w/ City Employee Operating
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?
No
Dated at Dubuque, Iowa this 21 day of November , 2001 .
/s/ Kenneth M. Metz
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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. 13~h 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 C>AIM WILL OR WILL NOT BE PAID.
1. Name of Claimant
2. Address:
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, give the
employee's name.) j _~
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police investigate? (If so= give names of.o~icers.)
/
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? ~Y~-~., ~/c,~ ~. ~5~'~
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.)
18. if the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount?
:O
Dated at Dubuque, Iowa this C~ / day of
(Print Name)
(Rev. 1/00 & 7/01)
WILSON BROS. DODGE
90 JFK
DUBUQUE, IA 52002
PHONE: (319)583-5781
CD LOG NO 1488-1 DATE 11/20/01
SHOP:
ADDRESS:
CITY STATE:
ZIP:
WILSON BROS AUTO BODY
90 JFK
FED TAX ID 420779647
DUBUQUE, IA
52002-
INSP DATE:
CONTACT:
PHONE 2:
FAX:
11/20/01
(319)556-6928
OWNER: METZ, KENNETH
ADDRESS: 2303 WASHINTON
CITY STATE: DUB, IA
ZIP: 52001-
HOME PHONE:
(563)583-0094
POINT OF IMPACT: 10
LIC#:
BODY COLOR: RED
CONDITION:
STATE:
VIN:
MILEAGE:
ACCTNG CTL%:
1B7GE16Y4LS762131
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
TE=PARTL REPL PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
E=REPLACE OEM
EU=REPLACE SALVAGE
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I ASSEMBLY
RP=RELATED PRIOR
NG=REPLACE NAGS
EP=REPLACE PXN
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
1990 DODGE RAM 150 STD 2DOOR STANDARD CAB
CODE: N8153D/G OPTNS J/24S
8CYL GASOLINE 5.2
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
POWER STEERING
TWO-STAGE - INTERIOR SURFACES
OP GDE MC DESCRIPTION
E 0005
E 0O08
E O009
E 0033
MFG.PART NO.
BUMPER, FRONT 4249818
BRKT, FRONT BUMPER M LT 4428385
BRKT,FRONT BUMPER M RT 4428384
INSERT,GRILLE
CHROME
E 0030 FRAME, GRILLE
E 0031 PANEL, GRILLE LOWER
L 0031 PANEL, GRILLE LOWER
E 0072 DOOR, HEADLAMP
I 0390 PANEL,BEDSIDE
L 0390 09 PANEL, BEDSIDE
E 0586 TAILLJ~MP ASSEMBLY
E 0568 BUMPER, REAR STEP
4249802
4249801
4443855
REFINISH
RT 4249812
RT REPAIR
RT REFINISH
RT 55054788
55029883
PRICE
342.00.
23.45
23.45
158.00
194.00
92.00
64.70
58.00
412.00
AJ% B%
HOURS R
0.91
1
1
1
1.2 1
0.61
1.04
1
7.0'1
4.94
0.2 !
0.81
PAGE 1
199Q DODGE'RAM 150
qD~OG NO 1488-1
STD 2DOOR STANDARD CAB
E ~0573
E 0575
N Mt4
SB M60
N
I
BRKT,REAR BUMPER MT RT 4086366 22.50
SUPT,RR BUMPER OUTE RT 4249866 18.25
CORROSION PROTECTION ADDNL LABOR OPERA 8.00*
HAZARD. WSTE. REM. SUBLET REPAIR 4.00*
RAND I FOG LAMPS ADDNL LABOR OPERA
FRAME HORNS REPAIR
1
1
0.2*4*
0.4'1'
1.0'1'
18 ITEMS
MC MESSAGE(S)
09 INCLUDES 0.6 HOURS MAJOR PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
OTHER PARTS
PAINT MATERIAL
PARTS TOTAL
TAX ON PARTS @
6.000%
1,408.35
8.00
152.50
1,568.85
84.98
LABOR RATE REPLACE HRS REPAIR HRS
1-SHEET METAL 40.00 3.7 8.4 484.00
2-MECH/ELEC 48.00
3-FRAME 45.00
4-REFINISH 40.00 5.9 0.2 244.00
5-PAINT MATERIAL 25.00
LABOR TOTAL 728.00
TAX ON LABOR @ 6.000% 43.68
SUBLET REPAIRS 4.00
TAX ON SUBLET @ 6.000% 0.24
TOWING
STORAGE
GROSS TOTAL
2,429.75
NET TOTAL
2,429.75
ADP SHOPLINK UB303 ES CD LOG 1488-1 DATE 11/20/01 10:42:59AM R6.2
PXN:N/00/00/00/00 CUM:/// HOST LOG
COPYRIGHT 2000, AUTOMATIC DATA PROCESSING, INC.
CD 11/01
!.5 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
PAGE 2