Claim by Erik Steffenson
CLAIM AGAINST THE CITY OF DUBUQUE, f~WA
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 13"' 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.
i
1. Name of Claimant: Erik Stefenson
2. Address: 711 Fenelon Place Dubuque, Iowa 52001
3. Telephone Number
SSA-`~~~7 U
4. Date of Incident: ~,~ /~
5. Time of Incident:
6. Location of Incident (Be specific
Hacienda Community Home - Area Reasidential Care - Parking Lot
2429 Hacienda Drive, Dubuque, Iowa
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 n
_~y LG ~
8. What weree weathers~ndition like?
9. Give na a and a dress of any witne ses: _
-~- ° ' `-e ~d ~l~u e vs
10. Did police investigate? (If so, give names of officers.)
c>~~ ~~ ~1~~,.~ ~~ - Cud ~n~w~l~r (~ `~~-qll~
vv~
11. Wks anyone injured? (If so, give names, addresses, and extent of injuries).
/~/~~ --
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.)
.~
17. Have you made any claim against anyone else for damages as a result of
this i~pident? (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?
~ /J/J
Dated this ay of /! l ~A ~[ /` _, ?g~•~~~~~
~7~v°r, ~ ,a'~1'~al~~
.ff._. ~.
(Signature)
- a+, ~ZI !~d ~- ~~~ 80
fir, ~~ 5 (~ ~ -
(Print Name) ~~~`~~J~~
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
1~. Why do you claim tre City of Dubuque js responsible? ,~
'~f~
t
~~
Damage Assessed By: Robert Hanley
Date: 3/ 3/2008 02:27 PM
Estimate ID: 1346
Estimate Version: 0
Preliminary
Profile ID: MRchell
HANLEY AUTO BODY
1030 Century Circle, Dubuque, IA 52002
{563) 583-7220
Fax: (563)583-8355
Deductible: UNKNOWN
Owner: Erik Steffenson
Address: 711 Fenelon Place, Dubuque, U1 52001
Telephone: Hame Phone: (563) 556297
MRchell Service: 818528
Description: 2002 Chrysler Sebring LX
Body Style: 4D Sed
VIN: 1C3EL46R52N789860
Options: CRUISE CONTROL, AUTOMATIC TRANSMISSION
Line Entry Labor
Item Number Type Operation
1 801375 BDY REPAIR
2 AUTO REF REFINISH
3 801382 BDY REMOVElREPLACE
4 801421 BDY REPAIR
5 AUTO REF REFINISH
8 AUTO REF ADD'L OPR
T AUTO ADD1 COST
8 AUTO ADD1 COST
Drive Train: 2.7L Inj 6 Cyl 4A FWD
Line Item Part Type/
Description Part Number
R FRT DOOR SHELL Existing
R FRT DOOR OUTSIDE
R FRT DOOR REAR VIEW MIRROR "* QUAL REPL PART
R REAR DOOR SHELL Existing
R REAR DOOR OUTSIDE
CLEAR COAT
PAINT/MATERWLS
HAZARDOUS WASTE DISPOSAL
* -Judgment Item
# -Labor Note Applies
C -Included in Clear Coat Calc
I. Labor Subtotals
Body
Refinish
Labor Summary
Units Rate
3.2 48.00
4.8 48.00
Taxable Labor
Labor Tax
8.1
Add'I
Labor
Amount
0.00
0.00
Sublet
Amount
0.00
0.00
~ 7.000 %
Dollar Labor
Amount Units
2.0* #
C 2.1
105.00 * 0.2 #
1.0*
C 1.6
1.2
142.10 *
5.00 *
Totals II. Part Replacement Summary
153.60 T Taxable Parts
235.20 T Salo Tax ~ 7.00016
388.80 Total Replacement Parts Amount
27.22
416.02
III. Additional Costs Amount N. Adjustments
Non-T~~e Costs 147.10 Customer Responsibility
Total Additional Costs 147.10
ESTIMATE RECALL NUMBER: 03/03/2008 14:26:58 1346
UltraMate is a Trademark of Mitchell International
MRchell Data Version: FEB 08 A Copyright (C) 1884 - 2005 Mitchell International
UltraMate Version: 6A.028 All Rghts Reserved
Amount
105.00
7.35
112.35
Amount
0.00
Page 1 of 2
' Date:
'~ ~ Estimate ID:
Estimate Version:
Prelkrrnary
~, Profile ID:
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
N. Total Adjustments:
Net Total:
This is a areliminarv estimate.
Additional chan4es to the estimate may be required for the actual reaair.
ESTIMATE RECALL NUMBER: 03/03/2008 14:26:59 1346
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: FEB 08 A Copyright (C) 1994 - 2005 Mitchell International
UltraMate Version: 6.0.028 All Rights Reserved
3/ 3/2008 02:27 PM
1346
0
Mitchell
416.02
112.35
147.10
675.47
0.00
675A7
Page 2 of 2
HART AUTO BODY & PAINT DAMAGE REPORT
800 CEDAR CROSS ROAD DUBUQUE, IOWA 52003 PRICES SUBJECT TO CHANGE
PHONE: (563) 556-8323 FAX: (563) 556-8324 Items CIRCLED are not in the tots) to
our opinion, sro not part of this ela~m.
VEHICL OWNER ADDRESS PH NE DATE
~Ao Q ~ ~~ ~~ S ~ ~~D ~` LICENSE MILEAGE COLOR SERIAL NO. CONDITION
((
pp
I
N
SURANCE CO ADJUSTER PHONE CAR LOCATED AT DEDUCTIBLE
sym. FRONT sublet
Or Paint service ;
Or Hours
Parts
sym. LEFT sublet
Or Paint Serries ;
Or Hours
Parts
sym. RIGHT sublet
Or Paint service i
Or Houn
Parts
Bumper WlPads fender, Frt. Fender, Frt.
Bumper Abs. Fender Shield Fender Shield
Fender Ext. Fender Ext.
Fender Mldg. Side Fender Mldg. Side
Fender Stripe Fender Stripe
Fender Mldg. Fender Mfdg.
Bumper Reinf.
Bumper Brkt. Side Light Asmbly Side Light Asmbly
Bumper Cushion Headlamp Headlamp
Valance Headlamp Door Headlamp Dr.
Bumper Gd. Sealed Beam Sealed Beam
Frt. S stem Park Light Park Light
Froms Cowl Cowl
Cross Member Door, Front Door, Front
Wheel Door Hinge Door Hinge
Hub Cap Disc Door Panel Door panel
Lr. Cont. Arm poor Stripe Door Stripe
Door Mldgs. Door Mldg.
Up. Cont. Arm _ ~, ~~i~ ~<< 3( 0
Center Post Center Post
Door Rear J Door Rear
Bumper Filler Door Mldg. Door Mldg.
Grille
Grille Panel
Grill Panel Mldg. Rocker Panel
Rocker Panel
Rocker Midg. Rocker Mldg.
Floor Floor
Dog Leg Dog LeB
guar. Panel guar. Panel
Air Condenser guar. Ezt. guar. Ext.
Recharge System guar. Wheel House guar. Wheel House
Name Plate quay. Mldg. Side guar. Mldg. Side
Baffle, Upper guar. Mldg. guar. Mldg.
Lock Plate, L-. guar. Stripe guar. Stripe
Lock Plate, Up. Side Light Asmbly Side Light Asmbly
Hood Top Tail Light Tail Light
Hood Hinge REAR MISC.
Hood Lock Bumper Inst. Panel
Ornament Bumper Abs. Front Seat
Rad. Sup. Bumper Cushion Front Seat Adj.
Rad. Core Bumper Reinf. Top
Anti Freeze Bumper Brkt. Headlining
Rad. Hoses Bumper Gd. Top Vinyl
Fan Blade Bumper Filler Tire % Worn
Fan Shroud Valance Painting
Fan Belt Lower Panel
Aerial
Water Pump Floor Rust Proof
Water Pump Pulley Trunk Lid Battlry
Motor Mts. Trunk Mldg.
EPA WASTE OISPOSJLL CHARGE ,j` Q d
Lic. Light PARTS (Prices Subject To Invoice)
- `
SERVICES7~ HRS. @
f HR. ga . a 6
Windshield Gas Tank SUBLET OR PAINTING
Frame SUB TOTAL S~ p.
wheel TAX
Hub & Drum f
Azle PAINT-MATRL-HDW. d .
L
- Spring
GRAND TOTAL '~ 0 ~(,
Appraiser
Symbols:
A-Align N-New OP-0pen P-Paint 1 HEREBY AUTHORIZE THE ABOVE REPAIRS
S-Straighten R-Replace OH-Overhaul