Loading...
Claim by Chris BlakemanCLAIM AGAINST THE CITY OF DUBUQU~, IOIa/A 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: Chris Blakeman 2. Address: 911 High Bluff St. 3. Telephone Number: 563-582-1345 4. Date of Incident: 12/17/07 S~ 12-~1~ v7 5. Time of Incident: (il 6. Location of Incident (Be specific): In front of 2620 Central 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.) f'1 L ~ ~ ~~ C~'f ~ U ~ (~(~ ~Q ~ Vl (I ~l I ~ U. ~/~ ~ ('v~ C l/~ I~ i ~ T ~ _ Cat ~~'iI ~( i r~ 0 r~ , ~- i ~0 ~~c~e ~'~ Mo~t~, 8. What were weather conditions like? ~~ ~ CA i T h~~~~ ~~ Cv .n ~ I , r ~~1 ~I,r~Q_UI . p 1 9. Give name and address of any witnesses: ~tU~a,~ l~re~5or~ ~ 1a~2~; ~~.~, , 4f ~. 10. Did police investigate? (If so, give names of officers.) a 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.) ~d 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.) 0 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the City of Dubuque is res~pgqnsible? Tin k~~ r ~ h~ ~- ~,..i w,.; r~~~ . a~~ ~- pus ©qr~d w~~ ~ ~I oc~ ~-c~ -~(~ C ~ ~ 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? Dated at Dubuque, Iowa this day of ~~, ti 20~. r, (Rev. 1 /00 & 7/01) a I~~.r. Signature) (Print Name) dl "cn~ngnQ 6 I ~Z lid 0 I Ndl' 80 0.1/04/•2008 at 04:33 PM 24443 ABRA - DUBUQUE Federal ID #:420782245 DBA: ANDERSON-WEBER INC 3400 CENTER GROVE DR DUBUQUE, IA 52003 (563)556-0696 Fax: (563)556-1899 PRELIMINARY ESTIMATE Written By: RICK KELLY Adjuster: Insured: Owner: Address: Evening: Business: CHRIS BLAKEMAN CHRIS BLAKEMAN 911 HIGH BLUFF DUBUQUE, IA 52001 (563)582-1345 (563)543-7740 Inspect ABRA - DUBUQUE Location: 3400 CENTER GROVE DR DUBUQUE, IA 52003 Insurance Company: Claim # Policy # Deductible: Date of Loss: Type of Loss: Point of Impact: Job Number: Business: (563)556-0696 Days to Repair 2005 FORD F150 4X4 SUPERCAB 8-5.4L-FI 4D SHORT Int: VIN: 1FTPX14505FB66089 Lic: Prod Date: Odometer: Air Conditioning Tilt Wheel Intermittent Wipers Dual Mirrors Clear Coat_Paint Power Steering Power Brakes AM Radio FM Radio Stereo Search/Seek Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Rear Step Bumper Automatic Transmission 4 Wheel Drive Overdrive Styled Steel Wheels NO. OP. ----------------- DESCRIPTION -------------- QTY EXT. PRICE LABOR PAINT 1 ----------------- FRONT DOOR ------------------------------- 2* Repl LT Mirror assy w/o heat 1 105.27 0.5 0.0 3 R&I ----------------- RT R&I trim panel ------------------------------- 0 0.00 0.5 0.0 ---- Subtotals =_> --------------------------- 105.27 1.0 0.0 Parts 105.27 Body Labor --------------------- 1.0 hrs @ $ 52.00/hr 52.00 ---- SUBTOTAL --------------------------- $ 157.27 Sales Tax --------------------- $ 157.27 @ 7.000Oo 11.01 -- GRAND TOTAL ----------------------------- $ 168.28 1 G1/04%2008 at 04:33 PM 24443 Job Number: PRELIMINARY ESTIMATE 2005 FORD F150 4X4 SUPERCAB 8-5.4L-FI 4D SHORT Int: ADJUSTMENTS: Deductible 0.00 ---------------------------------------------------- CUSTOMER PAY $ 0.00 INSURANCE PAY $ 168.28 WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO INVOICE NO GIJARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MA04, CCC Data Date 12/01/2007, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (~) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 2