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Claim Ament, KevinCLAIM 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: Kevin Ament 2. Address: 1600 Marmora, Dubuque IA 52001 3. Telephone Number: 556 5428 4. Date of Incident: Feb. 7, 2001 5. Time of Incident: 10:10 P.M. 6. Location of Incident (Be specific): 1600 Marmora Car parked in front of home 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.) Was awakened at about 10:10 p.m. on Feb. 7, 2001 by Philip Arensdorf (Ambulance Driver) knocking on my door saying he slid into my car. 8. What were weather conditions like? Icy 9. Give name and address of any witnesses: Sharon Menadue her (husband) Jim said she seen it. 10. Did police investigate? (If so, give names of officers.) Dave Haupert 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.) 1993 Plym Duster Passenger side of car wa shit. Damage done to bumper, rear back panel and door 13. What other damages do you claim, if any? Flat tire and rim is damaged beyond repair. 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? $2900.72 car estimate $14.82 flat tire. = $2915.54 16. Why do you claim the City of Dubuque is responsible? Ambulance driver hit my car while it was parked at curb in front of my home. 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 21 day of Feb., 2001. , 20 . /s/ Kevin G. Ament (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 fo~m 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 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 Name of Claimant: Address, Telephone Number: Date of Incident: PAID. 1. 2. 3. 4. 5. 6. % Time of Incid.nt: '/©; I0 ? Location of incident. (Be specific) 110/90 7. DESCRIBE ACCIDE~ OR OCC~RENCE ~T CAUSED INgu~Y OR D~GE. (Give full details upon which you base your claim, if a City ~ployee was involved, give the ~ployee's n~e.) 8. ~at were weather monditions lmke? ~ ~ 9. Give n~e and address of any witnesses. .~?o~ 10. Pi8 polf=e inveCti~at~ (If ~o, giv~ nu~¢ of officer~.) 11. Was anyone injured? (if so, injuries. ) give name, address and extent of 12. Was any ds~nage 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. ~at other d~es do you claim, if any? any insurance company? (If so, give n~e ~d address of insurance ~ompany and ~o~t paid.) 15. What amount do you claim from the City of Dubuque? 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? ~0 If yes, give name and address: 18. If the answer to Question 27 ~_'~ yes, have you received any payment from that source, and if so, in what s~ount? Dated at Dubuque, Iowa, this Ab day of (~r', '~t ~'~e) Like No Other Tire Store CASH OR AUTHORIZED CREDIT CARD PURCHASE ONLY [~AM [~AM r-~PM r~PM scud KEVIN AMENT TO 1600 MARMORA DUBUQUE, IA 58001 STOr.$ DUBUQUE TIRES PLUS 4103 MCDONALD DRIVE DUBUQUE~ IA 58002 (319)584-0341 ~_AURENC_ SLOMAN 08/08/01 41317 ~:58 PM 3195565428 SHIP TO Cash COMPUTERIZED ALIGNMENT CHECK 1 0.00 *HOW IT TURNS OUT. WOULD YOU *WOULD YOU LIKE THEM BALANCED REPLACED VALVE STEM 1 0.00 8.00 SHOP SUPPLIES/TIRE 1 2.99 2.99 8 1 u 00 8.00 WORK AUTHORIZED BY DATE GUEST COPY SOlD KEVIN AMENT PM ?O 1600 MARMORA DUBUQUE, IA 52001 2195565428 SUNDANCE S?OP.E DUBUQUE TIRES PLUS 4103 MCDONALD DRIVE DUBUQUE, IA 52002 (319>584-0341 SH~o TO 41317 88,308 *IMPACT CAUSED THE RIM TO BE BENT SO [, THE GUEST HAVE BEE~ OFFERED IME TIRE DATE PROTECTION PLAN,UNDERSTAi~DING THE DETAILS, OK'D BY AND HA~ ELECTED NOT TO ACCEPT THE ABOVE EXPLAII~ED WAILRANTY. INITIALS Inv Total : 34.28 I hereby authorize the above repafi; work to be done along with the necessary materials. You and yottr employees may operate above unk for purposes of testing, inspection or delivery at my risk. An express mechanics' lien is acknowledged on above unit to secure the amount of repairs thereto. It is understood that this company assumes no responsibililty for loss or damage by the~ or fire to unit or contents placed with them for storage, sale, repair or while tesling. Not responsible for loss or damage to cars or articles left in cars in case of fire, theft, or any other cause beyond our contel. WORK AUTHORIZED BY DATE GUEST COPY Date: 2/16/0102:07 PM Estimate ID: 3488 Estimate Version: 0 Preliminary Profile ID: Mitchell Riley's Olds-Mazda-Subaru 4450 Dodge St. Dubuque, IA 52003 (319) 008-2326 Fax: (319) 588-9286 Tax ID: 42-995727;' Damage Assessed By: KEITH KNIPPER Deductible: UNKNOWN Insured: KEVIN AMENT Address: 1000 ~..~ARMORA DUBUQUE, IA 52001 Telephone: Home Phone: (319) 556-5428 Mitchell Service: 913520 Description: 1993 Plymouth Duster Body Style: 2D HB VIN: IP3XP6432PNB05990 Options: AUTOMATIC TRANSMISSION Drive Train: 3.0L Inj 6 Cyl 4A Line Entry Labor Item Number Type Operation Line Item Description Part Type/ Part Number Dollar Labor Amount Units I 316280 BDY REMOVE/REPLACE Z 90553~ REF * ADD'L LABOR OP 3 317600 MCH ALIGN 4 331080 BDY REPAIR 5 AUTO REF REFINISH 6 338400 BDY REMOVE/REPLACE 7 AUTO REF REFINISH 8 AUTO REF REFINISH 9 AUTO REF REFINISH 10 345670 REF REFINISH 11 345870 BDY REPAIR 12 933001 REF ADD'L OPR t3 AUTO REF ADD,L OPR 14 933003 REF ADD'L OPR 13 AUTO ADD'L COST 16 AUTO ADD'L COST WHEEL ME'~ALFLA,¼ECOLOR FOUR WHEEL -M R FRT DOOR SHELL R FRT DOOR OUTSIDE R QUARTER OUTER PANEL R QUARTER PANEL OUTSIDE R QUARTER PANEL EDGE R LOCK PILLAR REAR BUMPER COVER REAR BUMPER COVER ADDL CLEAR COAT CLEAR COAT T;NT COLOR PAINT/MATERIALS HAZARDOUS WASTE DISPOSAL * - Judgement Item # - Labor Note Applies C - Included in Clear Coat Calc 4284991 Existing 4548106 Existing 118,00 0.3 1.9 4.0*# C 2.6 557.00 15.0 # C 2.0 C 0.5 C C 2.3 4.0* 2.1 450.00 * 9.00 * ESTIMATE RECALL NUMBER: 2/16/01 13:58:37 3488 UltraMate is a Trademark of Mitchell International Mitchell Data Version: FEB_01_A Copyright (C) 1994 - 2000 Mitchell international UltraMate Version: 4.0.004 All Rights Reserved Page I of 2 Date: 2/16/01 02:07 PM Estimate ID: 3488 Estimate Version: 0 Preliminmy Profile ID: Mitchell Add'l Labor Sublet I. Labor Subtotals Units Rste Amount Amount Totals Body 20.8 40.00 0.00 0.00 832.00 Refinish 18.0 40.00 0.00 0.00 720.00 Mechanical 1.9 40.00 0.00 0.90 76.00 Taxable Labor 1,628.00 Labor Tax ~ 6.000 % 97.68 Labor Summary 40,7 1,725,68 Il. Part Replacement Summary T Taxable Parts T Sales Tax T Total Replacement Parts Amount 6.000% III. Additional Costs Taxable Costs Sales Tax Non-Taxable Costs Total Additional Costs ~ 6~00% 9.00 0.54 450.00 459,54 IV. Adjustments Customer Responsibility I. Total Labor: I1. Total Replacement Parts: II1. 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. "I HEREBY AUTHORIZE THE REPAIR WORK HEREIN SET FORTH TO BE DONE (INCLUDING PARTS AND MATERIALS) AND AGREE TO MAKE PAYMENT TREREFORE IN CASH, UNLESS IT IS OTHERWISE AGREED AND SO SET FORTH IN THIS ORDER. I UNDERSTAND THAT AS A MATTER OF IOWA LAW YOU MAY RETAIN POSSESSION OF THE VEHICLE UNTIL SUCH CASH PAYMENT IS MADE. YOU ARE NOT RESPONSIBLE FOR ANY DELAYS CAUSED BY UNAVAILABILTY OF PARTS OR DELAYS IN PARTS SHIPMENTS NOR FOR LOSS OR DAMAGE TO ~HICLE IN CASE OF FIRE, THEFT OR ANY OTHER CAUSE BEYOND YOUR CONTROL". x 675.00 40.50 715.50 Amount 0.00 1,725.68 715.50 459.54 2,900.72 0.00 2,900.72 ESTIMATE RECALL NUMBER: 2/16/01 13:58:37 3488 UltraMate is a Trademark of Mitchell International Mitchell Data Version: FEB_0 I_A Copyright (C) 1994 - 2000 Mitchell international UltraMate Version: 4.6.004 All Rights Reserved Page 2 of 2