Claim Grove Tool - Smith, R.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: Grove Tool Inc (Robert Smith)
2 Address: 3230 Dodge St. City
3. Telephone Number: 319 588 0536
4. Date of Incident: 01 02 01
5. Time of Incident: 1:13 P.M.
6. Location of Incident (Be specific): 400 Blk W. Locust
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.)
My vehicle was parked bus hit my right mirror - bus driver was Joihn A. Reno
8. What were weather conditions like?
Clear
9. Give name and address of any witnesses:
Yes Flannery
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
Estimate Attached
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, Right mirror $209.00
Estimate attached
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?
$209.00
16. Why do you claim the City of Dubuque is responsible?
The bus hit my vehicle
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 8 day of Jan. , 2001.
/s/ Robert Smith
(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
reco~endation 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.
2.
3.
4.
Name of
Telephone Number: 3/
Date O~ InCiden~:-~/
5. Time of Incident: ~'/~ ,~4,F
6. Loca~i~ of incia~nt. (Be specific~ ~:~'~:]Z~("
10.
11.
DESCRIBe-ACCIDENT OR OCCURRENCE T~ATCAUSED INouKY OR DAMAGE.
(~ivefull details upon~which you base your claim. If a City
employee was involved, give the employee's name.)
8. What were weather conditions like? ~L ~
9. Give ~ame and address of any witnesses. ~' ~,
.......... ~ Q ~, ~
Did police investigate? (If so, give names of off.~c~?rs.~ ~
Was anyone injured? ( o, give name, address and 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.
14.
What other d~ages do you claim, if any?
Have :you been compensated for any part or all of your claim by
any insurance coml~any? (If so, give name and address of
insurance company and amount paid.)
15.
16.
What ~unt do you claim from the City Of DUbuque?
Why do you claim the City of DUbuque is responsible?
17.
Have you ~ade any-claim against anyone else for dsanages as a
result of this incident? /~/~ .
If yes, give name and address:
18. .If the answer to Question 17 ~s ~es, have you received any
Dated at' DUbuque, IOwa, this ~ day of ~. ''
20~/ ·
(Revised January, 2000)
(P~rint Name)
Date: tl4/01 11:26AM
Estimate ID: 4339
Estimate Version: 0
Preliminary
Profile ID: Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 67 DUBUQUE, IA 52061
(319) 083.-9t21
Fax: (319) 656-4482
Damage Assessed By: JOHN KLOTZ JR.
Deductible: UNKNOWN
Owner GROVE TOOL
Mitchell Service: 914498
Description: 2600 Chevrolet Suburban K1600 LT
Body Style: 40 Ut
VIN: 3GNFK16T6YG105734
Options: 4 WHEEL DRIVE
Drive Train: 5.3L Inj 8 Cyl 4WD
Line Entry Labor Line Item Part Type/
Item Number Type OperaUon Description PartNumber
Dsiiar Labor
Amount Units
I 401192 BDY REMOVE/REPLACE
2 AUTO REF REFINISH
3 AUTO REF ADD'L OPR
4 AUTO ADD~L COST
6 AUTO ADD'L COST
L FRT DOOR REAR VIEW MIRROR
L FRT DOOR MIRROR
CLEAR COAT
PA]NTIMATERIALS
HAZARDOUS WASTE DISPOSAL
'15757596 GM PART
150.00 0.2 #
C 0.5
0.1
t6.60 *
0.48 *
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
I. Labor Subtotals Units
Body 0~. 40.00
Refinish 0.6 40~00
Add'l
Labor Sublet
Rate Amount Amount
Totals II. Part Replacement Surrmlary
0.00 0.00 8.00 T Taxable Parts
0.00 0.00 24.00 T Sales Tax ~
Taxable Labor 32.00 Total Replacement Parts Amount
Labor Tax ~ 6,000 % %92
Labor Surrd~nary 0.8 33.92
IlL AdditionalCnsts Amount IV. Adjustments
Non-Taxabls Costs 16.08 Customer Responsibility
Total Additional Costs '/6.08
ESTIMATE RECALL NUMBER: 11410111:24:20 4339
~ UltraMste is a Trademark of Mitchell Int~mstioesl
Mitchell Data Version: ' DEC_00_A Copyright (C) 1994 - 2000 Mitchell Intemsi]onsi
ultraMate Version: 4.6.004 Ait Rights Reserved
Amount
150.00
9.00
0.00
page I of 2
Date: 114/01 11:26AM
Est~mate ID: 4339
Estimate Version: 0
Preliminary
Profile ID: Mitchell
I. Total Labor:
II. Total Replacemeot Parts:
Ill. Total Additional Costs:
Gross Total:
iV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
PARTS PRICES ARE SUBJECT TO CHANGE
33.92
159.00
16.08
209.00
ESTIMATE RECALL NUMBER: 1/4/0111.-24:20 4339
UitraMate is a Trademark of Mitchell international
Mitchell Data Version: DEC._00_A Copyright (C) 1994 - 2000 Mitchell Intemstiona!
UtiraMste Version: 4.6.004 Ali Rights Reserved
Page 2 of 2
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