Claim by Regina Pint~ ~ /
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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: Regina Pint
2. Address: 3870 Cora Drive, Dubuque, IA
3. Telephone Number !~ ~ ~- ~~ - ~O ~~
4. Date of Incident: ~~~- ~- O s~'
5. Time of Incident: i~ ~~ `~
6. Location of Incident (fie specific):
W. 9th St. Dubuque, IA
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.l
9. Give name and address of any witnesses~_
10. Did police investigate? (If so, give names of officers.)
8. What were weather conditions like?
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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.)
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13. What other damages do you claim, if any?
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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 a ount do you claim from the City of Dubuque?
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16. Whyydo you claim the City of Du uque 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?
Date(~7'~y_~,\'ils ~- '~ ay of /~ ~ ~~~ , 20 Q~'' .
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(Sign tire)
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(Print ame) CJ~/~I~J~c~
Drivers Name - Last
u SCHLICHMAN
Address
651 ENGLISH LANE
Gender I Drivers License Number
T Male
001 Owner Company Name
Driver Information Exchange Report
First
DOUGLAS
Class
B,M
State
IA
Dubuque Police Department
563-589-4410
City
DUBUQUE
Endorsements
p
Middle
LEE
Restrictions
NONE
Suffix
State
IA
Zip
62003
Insurance Co. Name
IOWA COMM. ASSURANCE
Insurance Policy #
ICAP0300 (7198)
Owner's Name - Last
CITY OF DUBUQUE KEYL
Address
50 W 13TH ST
First
1
VIM No.
4RKJNTFA62R835549
Year
2002
License Plate # State
85983 IA
Make
RTS
Year
2020
Middle
City
DUBUQUE
Model
Most Damaged Area
02 - Right Front
Suffix
State
IA
Zip
52001-
Style
BU
Insurance Co. Phone #
(563) 589-4100 x
Vehicle Configuration
18
Approximate Cost to Repair or Replace
$400.00
Driver's Name - Last
N Address
T Gender
002 Owner Company Name
Owners Name - Last
PINT
First
Driver's License Number � Class
State
Middle
City
Endorsements) Restrictions Insurance Co. Name
NONE NONE CINCINNATI
Suffix Date of Birth
First
REGINA
Middle
LOLA
State
Insurance Policy #
CAP7714848
Zip
Suffix
Phone
Insurance Co Phone #
(563) 556-2084 x
Address
2511 PENNSYLVANIA AVE
VIN No.
1FMZU74K22U019441
License Plate #
723THS
Year
2002
1 State
I IA
Make
FORD
City
DUBUQUE
Model
XPL
Year Most Damaged Area
2008 08 - Left Front
State
IA
Zip
52001-
Style
SW
Vehicle Configuration
04
Approximate Cost to Repair or Replace
$600.00
County
Dubuque -31
Literal Description
W 9TH ST
Accident occurred within corporate limits of (city)
Dubuque -2100
X-Coordinate
00691517
If accident occurred outside of city
limits show generai vacinity. "NlA"
On Road. Street, or Highway:
W 9TH ST.
Distance
30 Ft
1
Direction
3-E and
Definable intersection, bridge, or railroad crossing
BLUFF ST.
Officer
DEUTSCH, BRUCE
Direction
"NIA" of
Distance
"NIA"
Nearest City
"NIA•.
Y-Coordinate
04708062
At Intersection with:
"NIA"
Direction
"NIA"
Badge No.
30
of
Milepost Number
"NIA" Cr
Law Enforcement Case Number
01-08-10088
Route (Cardinal)
I Travel Direction "NIA"
Date of Accident 'rime of Accident
03/04/2008 12:59 _ rirs.
Printed At: Dubuque Police Department 03r0412008 01 :30 PM
Page 1 Form It: 01-D8.1 Ooat
YAGER AUTO BODY INC
4488 DODGE ST
DUBUQUE, IA 52003-2600
PHN: 563 557 7376 FAX: 563 557 1709
*'* PRELIMINARY ESTIMATE ***
............
Owner
Owner: REGINA PINT
Address: Cell: (563)599-2961
City State Zip: DUBUQUE, IA F,e,X;
Control Information
Inspection
Inspection Date: 03/04/2008 01:53 PM
Driveable: Yes Rental Assisted:
Appraiser Name: CJ YAGER
Repairer
Repairer YAGER AUTO BODY Contact:
Address: 4488 DODGE ST Work/Day: (563)557-7376
City State Zip: Dubuque, IA 52003 Work/Day:
;,,Vehicle
2002 Ford Explorer Eddie Bauer 4 DR Wagon
6cyl Gasoline 4.0 FLEX
5 Speed Automatic
Lic.Plate: 723 THS VIN: 1 FMZU741<22UD19441
Mileage: 150,000 Mileage Type: Actual
Ext. Color: MAROON Int. Color:
Ext. Refinish: Two-Stage Int. Refinish:
ama es
.....
Line Op Description ADJ% B% Price Labor
1 Replace OEM Mirror,Outer R/C LT $152.66 $34.30
1 Items
Totals _ ___ u..~.. W _.. ,..
Parts $152.66
Body Labor $34.30
Tax $13.09
Estimate Total 5200.05
Insurance Pay: 5200.05
Customer Pay: 50.00
Audatex Estimating 5.0.322 ES 03/04/2008 01:58 PM REL 5.0.322 DT 02/01/2008 DB 03/01/2008
03/0412008 01:58 PM
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