Claim by Masahiro Iwasaki
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 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: Masahiro Iwasaki
2. Address: 560 Hill Street
3. Telephone Number ~.~~ ~1 .~`~L~D ~~
4. Date of Incident: y~ - U d` - ~fl X
5. Time of Incident: ~~ = ~
6. Location of Incident (Be specific):
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7. Describe the 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.) U
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8. What were weather conditions like?
9. Give name and address of any witnesses:
10. Did police invest`ig~ate/?~ (If so, give names of officers.)
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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.)
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15. What amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give name and address.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated this % ~ day of ~ , 20~~ f'~~I ~8n~ngnQ
~ b.)I~!(~ ~ `eta,-'i~ f '41~.J
~~~~ ~~z~
(Signature) ~0 ~ I I Nd Q ! M~(' 80
~aS'G~r ~x~ .~u/~sc ~~~ CJ~111~J~ci
(Print Name)
Driver Information Exchange Report
Drivers Name - Last
POLLOCK
First
DAWN
Address
726 RHOMBERG AVE
Dubuque Police Department
563-589-4410
Middle
MICHELLE
City
DUBUQUE
T Gender rs License Number
Female
001 Owner Company Name
CITY OF DUBUQUE KEYLINE TRANSIT
Class
B
State
IA
Endorsements' Restrictions
P NONE
Owner's Name - Last
First
Address
60 W. 13TH ST
VIN No.
T7W603A428
License Plate #
64437
Year Make
1979 GMC
State Year
IA 2008
Middle
City
DUBUQUE
Model
RTS
Most Damaged Area
Suffix Date of Birth
Stale Ip
IA 52001-0000
Insurance Co. Name
IOWA COMMUNITIES POOL
Insurance Policy #
Suffix
State I Zip
IA 52001-
Phone
(663) 5894198 x
Insurance Co. Phone #
(663) 589-4198 x
Style
BUS
i
Vehicle Configuration
16
Approximate Cost to Repair yr i2yNt. U
$0.00
Driver's Name - Last
U IWASAKI
N Address
560 HILL STREET
T
002
Gender
Male
Driver's License Number
Owner Company Name
First
MASAH1R0
Class
C
State
IA
City
DUBUQUE
Endorsements
NONE
Middle
Restrictions
B
Owner's Name - Last
IWASAKI
Address
560 HILL STREET
VIM No.
2HKRL18012H511019
License Plate
627SMJ
First
MASAHIRO
Year I Make
2002 [ HOND
`State Year
IA 2008
Middle
'Suffix Date of Birth
iSlate I Zip
IA 62001
Insurance Co. Name
STATE FARM MUTUAL
Insurance Policy #
G08-9800-F02-1BB
Suffix
Phone
(563) 583-0737 x
Insurance Co. Phone'# I
(563) 583-8301 x
City State Zip
DUBUQUE 'State
62001-
Model Style f Vehicle Configuration
ODY VN I 03
Most Damaged Area Approximate Cost to Repay or Repf.:v
01 - Front $300.00
County
Dubuque-31
Literal Description
CLARKE DR
Accident occurred wlth'n corporate limits of (city)
Dubuque-2100
X-Coordinate
00689465
If accident occurred outside of city
limits show general vacinity:
On Road, Street. or Highway:
CLARKE DR.
Distance
100 Ft
"NIA"
Direction
7-W
and
Direction
"NIA" of
Nearest City
"NIA"
Distance
"NIA"
rY-Coordinate
04708595
At Intersection with:
"N/A"
Route (Cardinall
Travel Direction "NIA"
Direction
"N/A" of
Milepost Number
"NIA" Or
Definable intersection, bridge, or railroa
W. LOCUST
Officer
HEFEL, JOHN
crossing
Badge No.
41A
Law Enforcement Case Number
01-08-1153
Date of Accident
01/08/2008
Time or Accident
14:29 His
Printed At: Dubuque Police Department 01108l2008 03:08 PM
Page 1 Form #: 01-08-1153
r RICHARDSON MOTORS
1475 J.F.K. ROAD
DUBUQUE, IA 52002
PHONE: (563) 582-5411 FAX: (563) 582-4129
FEDERAL ID: 42-0813744
CD LOG NO 3853-1
DATE 01/09/08
SHOP: RICHARDSON MOTORS
ADDRESS: 1475 JOHN F. KENNEDY RD
CITY STATE: DUBUQUE, IA
ZIP: 52002-
OWNER: IWASAKI, MASAHIRO
ADDRESS: 560 HILL
CITY STATE: DUBUQUE, IA
ZIP: 52001
POINT OF IMPACT: 4
LIC#: STATE:
BODY COLOR:
CONDITION:
*=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
INSP DATE: 01/09/08
CONTACT: JASON CHARLEY
PHONE l: (563)582-5411
FAX: (563)582-4129
HOME PHONE: (563)583-0737
VIN: 2HKRL18012H511019
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
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
2002 HONDA ODYSSEY EX 4DOOR PASSENGER VAN 6CYL GASOLINE 3.5
CODE: H6112B/D OPTNS A/24DGJ
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES TWO-STAGE - INTERIOR SURFACES
DRIVER POWER SEAT LUGGAGE RACK
CLIMATE CONTROLLED A/C
OP
-- GDE
--- MC DESCRIPTION
-- ----------- MFG.PART NO. PRICE AJ% B%
N
0006
FRONT BUMPER COVER ------------ ----- --- --
R&I ADDNL LABOR OPERA
I 0006 COVER, FRONT BUMPER REPAIR
L 0006 13 COVER, FRONT BUMPER REFINISH
SB M60 HAZARD. WSTE. REM. SUBLET REPAIR 6.00*
HOURS R
1.3 1
1.0*1
3.8 4
1*
4 ITEMS
MC MESSAGE(S)
13 INCLUDES 0.6 HOURS FIRST PANEL TWO-STAGE ALLOWANCE
?_002 HONDA ODYSSEY EX 4DOOR PASSENGER VAN
`CD LOG NO 3853-1
FINAL CALCULATIONS & ENTRIES
PAINT MATERIAL 121.60
PARTS & MATERIAL TOTA L 121.60
LABOR RATE REPLACE HRS REPAIR HRS
1-SHEET METAL 51.00 2.3 117.30
2-MECH/ELEC 60.00
3-FRAME 55.00
4-REFINISH 51.00 3.8 193.80
5-PAINT MATERIAL 32.00
LABOR TOTAL 311.10
TAX ON LABOR @ 7.000% 21.78
SUBLET REPAIRS 6.00
TAX ON SUBLET @ 7.000% 0.42
TOWING
STORAGE
GROSS TOTAL 460.90
NET TOTAL 460.90
SHOPLINK UN189 ES CD LOG 3853-1 DATE 01/09/08 11:05:19AM R6.37 CD 12/07
PXN: Y/00/00/00/00/00 CUM 00/00/00/00/00 GEOCODE 52002
EDU: 0101 HOST LOG
(C) 1998 - 2007 AUDATEX NORTH AMERICA, INC.
1.1 HRS WERE ADDED TO THIS EST. BASED ON AUDATEX TWO-STAGE REFINISH FORMULA.
ichardson oeo.M
Buick Cadillac GMC T[Iick Honda VE~f O~MA M(( Auu~cr
Drop oH. Relax. Piiicup.
Jason Charley
Body Shop Manager
Body Shop Hours: 8 a.m. - 5 p.m. Mon. -Fri
Business 563-582-5411 1475 John F. Kennedy Rd.
Toll Free 888-806-5411 Dubuque, Iowa 52002
Fax 563-582-4129 jcharley~richardsonmotors.com