Claim by Gary A Lungwitzr
~~,
~G~~i r
CLAIM AGAINST THE CITY OF DUBUQUE, IOW~~n ` ~
' t laim a ainst the City of Dubuque, Iowa. You
This wntten report constitu es your c g
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~.,~tn
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 ail 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: Gary A Lungwitz
2. Address: 2325 Roosevelt
3. Telephone Number 5 3 5 tj3/ 9 5~ z
4. Date- of Incident: ~~ ~ -- 2 c~`
5. Time of Incident: ~ i 3~ R ~/l
6. Location of Incident (Be specific): In alley in front of my house
n? ~ .~
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.)
,:n~ra~r~. ~"r~~-~, 5~~~ s~~.~~,~rvs rNt-v wry _GR.~-
8. What were weather conditions like?
CL~~r`
9. Give name and address of any witnesses:
1N ~ .~ ;, rya _~('~ t:U ~, (.. ~ ,v ~ ,~ 3 a 3 ~ ~ o S z ~~ z. L -t"
10. Did police investigate? (If so, give names of officers
ova
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? ~L' _~_~_~
~------
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.)
ice'
15. W~at amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
~r i4 ~' ~ ~r'A.- ~,N erg-- +~ ~ r ~. 7'li -t- Q rn n i A. .
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?
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Dated this _ (z_ day of ~~~/a/~ c ~ ~ 20
(Signa ure)
(Print Name)
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03/06/2008 at 11:43 AM
30799
Job Number:
BRIMEYER AUTO BODY
License #:30799 Federal ID #:421438480
10709 COLLISION DR.
DUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
PRELIMINARY ESTIMATE
Written By: KEVIN SMITH
Adjuster:
Insured: GARY LUNGWITZ
Owner: GARY LUNGWITZ
Address: 2325 ROOSEVELT
DUBUQUE, IA 52001
Evening: (563)543-1943
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
inspect
Location:
Insurance
Company:
Days to Repair
1992 TOYO CAMRY LE 4-2.2L-FI 4D SED WHITE Int:
VIN: JT2SK 12E4N0 055892 Lic: Prod Date: Odomete r:
Air Condit ioning Rear Defogger Tilt Wheel
Cruise Con trol Intermittent wipers Tinted Glass
Body Side Moldin gs Dual Mirrors Console/Storage
Clear Coat Paint Power Steering Power Brakes
Power Wind ows Power Locks Power Antenna
Power Mirr ors AM Radio FM Radio
Stereo Cassette Search/Seek
Driver Air Bag Cloth Seats Bucket Seats
Recline/Lo unge S eats Automatic Transmission Overdrive
Full Wheel
--------- Cover
- s
-
NO.
---------- -----
-
OP.
------- -------------------------------
DESCRIPTION
---------------------
---- ----
QTY ------------------
EXT. PRICE LABOR ---------
PAINT
1 -----
-
FRONT DOOR ---- ------------------ ---------
2 Repl LT Side molding upper LE, SE, 1 92.97 0.3
XLE
3 REAR DOOR
9* Repl LKQ LT door assy +25g 1 500.00 1.7 3.3
5 Add for Clear Coat 1.3
6 Repl LT Side molding upper LE, 1 37.01 0.3
XLE, SE
7 R&I LT Belt w'strip DX, LE, XLE 0.3
8 R&I LT Moveable glass tinted 0.5
Toyota
9 R&I LT Handle, outside LE, XLE 0.5
10* R&I LT Run channel 0.4
11 R&I LT Lock 0.5
12 R&I LT R&I trim panel 0.4
13 REAR LAMPS
19 R&I LT Tail lamp assy 0.5
15 QUARTER PANEL
16* Rpr LT Quarter panel 8.0 2.2
17 Overlap Major Adj. Panel -0.4
18 Add for Clear Coat 0.4
19# Repl W/0 MLDG 1 25.00 0.2
20 REAR BUMPER
21 R&I R&I bumper assy 1.0
22* Rpr Bumper cover 1.0 2.5
23 Add for Clear Coat 1.0
24# Repl TAPE STRIPE 1 15.00 0.2
25# Repl MASK FOR OVERSPRAY 1 5.00 Incl.
26#
----------- Repl
------ FLEX ADDITIVE
------------------------------- 1 5.00 Incl.
Subtotals =_> ---- ------------------
629.98 15.8 ---------
10.3
03/06/2008 at 11:43 AM Job Number:
30799
PRELIMINARY ESTIMATE
1992 TOYO CAMRY LE 4-2.2L-FI 9D SED WHITE Int:
Parts 629.98
Body Labor 15.8 hrs @ S 53.00/hr 837.90
Paint Labor 10.3 hrs @ $ 53.00/hr 545.90
Paint Supplies 10.3 hrs @ S 32.00/hr 329.60
------
------------------
SUBTOTAL -------- -------- ----------
$ --
2342.38
Sales Tax $ 2012.78 @ 7.000Oo 140.89
GRAND TOTAL S 2483.27
ADJUSTMENTS:
Deductible 0.00
----------------------------------------------------
CUSTOMER PAY S 0.00
INSURANCE PAY $ 2483.27
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide AEM8498, CCC Data Date 02/01/2008, 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
Toys Done Right
11941 Sherrill rd
Dubuque, IA, 52002
Te1:563-552-1601 Fax:563-552-2207
toysdoneright@yahoo.com
Tax ID: 26-1404014
I~ Estimate -Preliminary II
Estimate Prepared by: Appraised for:
Accident Date:
Date of Loss: Date: 3/6/2008
Arrival Date: Estimate#:
Type of Loss:
Policy Number:
Claim Number:
Owner:
Contact: Gary Lungwitz
Address: 543-1943
Year Make Model Color Trim
1992 Toyota Camry LE Sedan
Unit Number License Plate # Mileage Serial#/VIN#
JT2SK12E4N0055892
Sup Seq Qty Labor Labor Description Part Part List Extended Labor
Type Op Type Number Price Price Units
1 1 Ref Ref Refinish Door Exist 1.2*
Outside Sedan,
Wagon L blend
2 1 Body Rem/Rep Moulding, Side New 75732-069 $42.47 $42.47
(Adhesive) LE, XLE, 18
SE Model (P) Sedan,
Wagon L
3 1 Ref Ref Refinish Side Exist .5
Moulding L
4 1 Body Rem/Ins R&I Belt Moulding Exist 1.5#
L
5 1 Body Rem/Ins R&I Upper Moulding Exist .8#
L
6 1 Body Rem/Ins R&I Frame Moulding Exist .2
L
7 1 Ref Ref Refinish Door Exist 2.2
Outside L
8 1 Body Rem/Rep Panel, Door Repair New 67114-060 $218.14 T $218.14 5.5
Wagon L 31
Version 2.0 P-Page logic not included.
Database Edition CPL 08-02 Page 1 of 3
Sup Seq ~ Qty Labor
Type Labor
Op Description Part
Type Part
Number List
Price Extended
Price Labor
Units
9 1 Ref Ref Refinish Door
Outside Add for
Jambs R L Exist .5
10 1 Ref Ref Refinish Quarter
Outside L Exist 2.4
11 1 Ref Ref Refinish Fuel Door Exist .4#
12 1 Body Ref Panel Assy, Outer
Quarter LE, XLE, SE
Model L Exist 8.5#*
13 1 Ref Ref Refinish Side Upper
Moulding L Exist .5
14 1 Body Rem/Ins R&I Lower Side
Moulding L Exist .3
15 1 Body Rem/Ins R&I Lower Moulding
L Exist .2
16 1 Body Rem/Ins R&I Lamp Assy L Exist .4
17 1 Ref Ref Refinish Rear Cover Exist 2.2
18 1 Body Rem/Ins R&I Bumper Assy Exist 1.2
19 1 Body Rem/Ins R&I Mudguard L Exist 3
20 1 Body Rem/Ins R&I Mudguard R Exist .3
21 1 Body Repair Cover, Rear (P) Exist 1.5*
22 1 Body Ref Clear Coat Exist 2.5*
23 1 Body Rem/Rep Rust proof New $20.00 $20.00 .7*
24 1 Body Rem/Rep Cover for overspray New $10.00 $10.00 .2*
25 Paint Materials $316.80
* -Judgement Item
# -Labor Note Applies
Labor park
Body 24.1 Hrs @ $52.00 $1,253.20 Parts Subtotal $290.61
Refinish 9.9 Hrs @ $52.00 $514.80 Less Adjustments
Labor Total $1,768.00 Parts Total $290.61
Additional Costs and Operations
Addl. Costs/Ops Total $316.80
Taz
Labor Tax @ 7.00% $123.78
Parts Tax @ 7.00% $15.27
Tax Total $139.05
Totals
Sub Total: $2,514.46
Customer Resp. $0.00
Net Total $2,514.46
1992 Toyota Camry LE
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Database Edition CPL 08-02 Page 2 of 3
e above is an estimate based on our inspection and
oes not cover any additional parts or labor which may
e required after the work has started. Occasionally,
orn or damaged parts are discovered which may not
e evident on the first inspection. Because of this, the
bove prices are not guaranteed. Quotations on parts
d labor are current and subject to change.
This is a preliminary estimate. Additional changes to the estimate may be required for the actual repair.
RepairMate does not automatically include items required by many business repair partners. This application
allows the author to manually enter line items such as overlap deductions.
1992 Toyota Camry LE
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Database Edition CPL 08-02 Page 3 of 3
VEHICLE ACCIDENT INFORMATION
DATE: ~ ~ ~~ TIME: ~ ~ ~ t /PM
When exchanging information for vehicle accidents under $1,000 and the Police
Department is not called, the following information is needed to complete Vehicle
Accident Reports. `~ S [\ .~ ~ . _
7k 'i #` Mt * t * * * 71t * * 'k 7k * * * R # M * tk * * * * * * * * * * * A' * * * * fF * !t !` * * * }t * * * * 7k 14 * * it
City Vehicle Description:
Vehicle # ~ "~ ~ Name of Driver ~` F ~ y.~s ~ ~ ~ ~
Description of the Accident ~..~ C C' t„~ a~ ~~ ~ ~'~ ~n-~ ~ -' '~ i~ { ~ ~'"' ~~'~ k. ,~
Estimate of Damage $ ~~~~
Other Vehicle Description;
~`fer~ ~,~ ~~~~~,
Year C~ Make ~ ~~~~'?~'~
VIN #
-~,
Model ~ ~ ~ ~~ ~
License Plate ~ `~ ~ /'~ t.~.~
`~
Name ~ Address of Driver - Craig Soltow
Name 8~ Address of Owner ~
r~
Driver License Number ~
Is the Vehicle Drivable '~ `~~..
r--,
Insurance Carrier ~j.
Description of Damage to Vehicle ~~ ~ ~ ~' ~ , ~ ~ °~_,~ ~ ~~ ~ ~ x~ '~ 4
Estimate of "Damage $ ~O~i,~ `;~ `~'~ ~ ~P ' '~ i '~ r' ~ (over)
~~
_ ~.,
**If this accident or damage IS NOT investigated by the Police Department**
The City vehicle driver's Supervisor or Manager MIST complete this page
North
Use arrow to
Indicate direction
ACCIDENT DIAGRAM
••Position vehicles or objects in the diagram at the point of collision
J ~ I /
4-Way T -Intersection / Strai ht / No Interlectton Vehicle
g
Intersection Y -Intersection Symbol
~/ City Yekide labeled #1
OtbQ Vehicle labeled• #2
Contributing cheatappllcaatcs~-
Circumstances Yes No Briefly Describe Circumstance (s)
Road Surface Conditions
Road Defect
Weather Conditions
Driver's vision Obscured
Fixed Object Struck
Pedestrian Involved
ACCIDENT /DAMAGE PHOTOS ATTACHED: YES _ NO _ (ff not, reason: )
NOTE: ALL ACCIDENTS AND DAMAGE MUST BE PHOTOGRAPHED
NARRATIVE:
Completed By: Job Title: