Loading...
Claim by David J. ElginMar, 6. 2008 3:58PM State Farm Insurance No. 9503 P. 2 CLAIM AGAINST THE CITY OF DUBUQUE, lOWA~ This written report constltu~s your claim against the City of Dubuque, Iowa. You s ould complete this form in full and attach any sdditionai intormatlon that supports your claim. The Claim must be filed with the City Clerk at CHy Hail, ti0 W.13~' St, Dubugw, >A 52001. It will than be referred by the City Council to the appropriate departrnsnt for investigatlon. Once that investigation Is completied, a report and roaommendation wail be submitted to the City Council. You will be provided with a copy of that sport and recommendation. THE FINAL DECISION ON ALL CLAMNS IS MADE 9Y THE clef COUNCIL. NO EMPLOYEE OF THE CITY OF DUGtJQUE HAS THE AtJTHORRY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIMII WILL OR WILL NOT BE PAID. 1. Name of Ciaimant: David J. Elgin 2. Address:2619 Broadway St., Dubuque, IA 52001-1802 3. Telephone Number: .SGT 3 - 5'S,3 - .-s'n -y ~ ~~ 4. Date of Incident: 3 - 3 - ~ R 8. Time of incident: / b ~3S1 ~ 6. Location of incident (ee specifk): King and Broadway St. 7. DE8CRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMA©E. (Give full details upon whkh you base your claim. ff a .City employee was involved, glue the employee's name. . ~ ~ a w -#-2 Inc K / 8. What ware weather conditlons like? ~ 1 ~ ct ~ 8. Gtve name and address of ally witnesses: ____ t0. Did police trnestigate? {If so, glue names of oAlcers.) ~.! f S G FC rc ~ e //~ S~ h o /n c S [~ /a j n 3 4 ~. o n a Sc> ~ U l" D 8- Cr 9 .~ St T~ - -- e- 11. Was anyone Injured? (If so, give names, addresses, and extent of injuries). d„. S I .z ~d h ! ~t#W 80 Mar, 6. 2008 3.58PM State Farm Insurance No, 9503 P. 2 ~~~~ ~J ~~~~~~ CLAIM AGAINST THE CITY OF DUBUQUE, IOWA ~ti~ This written report constltutes your claim against the City of Dubuque, lows. You s ould complete thls foam in full and attach any additlonal informatlon that supports your claim. The Claim must be filed with the City Clerk at City Hail, f10 W.1J~' St, Dubugw, lA 52001. It will then be referred by the Ciiy Council to the appropriate depar6nent for investlgatlon. Once that investigatlon is completed, a report and rocommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. THE FINAL DECISION ON ALL CLANNS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OP DUBUQUE NAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 7. Name of Claimant: 2. Address: 3. Telephone Number: .~Cn 3 - 5-'Fs~ - .~sn ~/ > ~~ 4. Date of Incident: 3 - 3 - ~~ R 5. Time of Incident: / ~ '.~y a,n 6. Locnation of Incident (Be specific}: ni . oCJ~~7crb~Q ~OwG nr/--_-- 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full delsils upon whkh you base your claim. ff a City employee was involved, give the employee's name.) a w -~ ~c K 8. What wer® weather conditlons like? C 1 e 4 ,2 9. (live name and address of any witnesses: t0. Did police investigate? (If so, give names of officers.} \/~S GF~M.~ /~; ehe/tee S~ h jr~~S~a nASc> ~ Ul `GS- ~-r 9 ~~ 17. was anyone injurod? (If so, give names, addresses, and extent of injuries}. ~,/y Mar. b. 2008 3:59PM State Farm Insurance No, 9503 P• 3 12. Was any damage done to property? cif so, describe properly and the extierst of damages. Atmch estimates of damages or describe basis for ascertaining extent Of damage.) ~~ 1S. Wh~other damages do you claim, if any? --• _._. 14. Have you been compensated for any part or all of your elaim by any insurance company? (If so, Sive name and address of insurance company and amount paid.) ~~/y 15. What amount do you claim from the City of Dubuque? ~~ / Lo 8 • ~ Y -"~Rad ~~~,,, ~~; ~ ~ :. ol~~ n o n t~, e ~ sr~,•.~,~ ~e 16. Why do you claim the City of Dubuque is responsible? 17. Have you made any ciaim against anyone else for damages as a result of this incident? (If yes, give name and address.) n/o 18. If the answer to Question. l7 is yes, have you received any payment from that source, end if so, in what amount? Dated at Dubuque, Iowa this _~ day of !~c ,e n h , 20 08" . Name) ~~w.1roo ~ 701) Mar. 6f 2008 3:59PM State Farm Insurance 03/05/2008 at 09:42 AM 94529 TV1lPYN DCnGT 01P bVBIIQUE, LLC 90 KENNEDY RU DVBUQUE, IA 52001 (563)583-5781 Fax: (563)556-6928 PRBLIMIIi~AY ~9TIWITE Written By: TBRRY FORTMANN Adjuster: Yneured: DAVID ELGIN Claim Vwuar: DAVID ELGIN Bolicy Addr•ia: 2619 BROADWAY Deduotible: DUSUQVE, IA 52001 bate of Lone: Other: (563)582-5047 Typo of Loea: Point of Lopacts Inmpect r•oaation: No. 9503 P. 4 Job Number: Iasuraaee Compasyz Days to Repair 2001 DODG INTREPIb SE 6-2.7L-F2 4D sED Int: VI17: 2B3HD46R81H638984 Lic: prod Dade: OdOmetsr; Air Conditioning Rear Defogs@'r Tilt Wheel Cruise Coiltzol I~xtermitteilt Wipers Dual Mirrors ConsolQ/SLOrag@ Clear Coat paint Power Steering Power Brakes Power windows power Locks Power Mirrors Power Trunk/TailgaCe AM Radio FM Radio Stereo Cassette Search/Seek Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Bucket Seats Recline/Lounge Seats Automatic Transmissio n Overdrive Full wheel Covers N0. OP. DESCRIPTION ----------------- QTY EXT. PRICE LABOR PAINT 1 ----- REAR BUMPER =--- ---- 2 Rep1 Bumper Dover 1 394,00 1 6 3 2 3 Add for Clear CgAt . . 4 REAR DOOR ' 1.3 5 Blnd RT Door shell 6 TRUNK LID 1 2 7 Blnd Trunk lid 8 QUARTER PAj1EL 1 2 9* Rpx RT Quarter panel 6 5 10 Add for Clear Coat . 2.4 11# STRIPES 1 20.00 0 5 1.0 12 REAR Y,AMPS . 13 Repl RT Tail lamp assy 1 184.00 O q 14# - FRONT END ALIGNMENT 1 , 1 5 15~k HAZARDOUS WASTE 1 . M 5.00 T 1 Mar. 6: 2008 4,OOPM State Farm Insurance No, 9503 P. 5 03/05/2008 at 09;42 AM 94524 Job Number: DRDLYIKYNARY SSTII~-Z'E 2001 DODG INTREPYb SE 5-2,7L-FI 4D SED Irlt; O. OP. DESCRIPTION QTY EXT. P~tICE LA$OR PAINT 16# CAR COVER 1 5 00 T r 17# TRANMISSION OPEN . 1 Subtotals =_> ------- 608.00 -- --------- 10.5 ------- 10.3 Parts Body Labor 9.0 hrs @ $ 52,001hr 598.00 468 00 Paine Labor 10.3 hrs @ $ 52.00/hr . 535 60 Mechanical Labor 1.5 hrs A $ 52.00/hr . 78.00 Paint SuppliQS 10.3 hrs @ $ 32.00/hr 329.60 Sublet/Misc . --- 10.00 SUB'1'OTAL ---------- -- ---------- $ --- 2 019 2 0 Sales Tax $ 2019.20 @ 7.0000 141.34 GRAND TpTAlr $ 2160.54 ADJUSTMENTS: Deductible 0.00 cusmdMBR pA'fC g o , o0 INSURANCE FLAY $ 2160,54 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR3PtF98, CCC Data Date 02/01/2006, and the parts 9@1CCted are OEM-parts manufactured by [he vehicles pri0inal Equipment Manufacturer. OEM parts are availablQ at OE/Vehicle dealerships. OPT OEM (Optional OT,.M) Ox ALT OEM (Alternative 0$MI parts are OEM parts that may be provided by or through alternate soGrcea other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OSM or ALT pEM parts may include ^Hlomished^ parts providod by OLM's Chrough OEM vehicle dealerships. Asterisk (+) or Rouble Asterisk ("""~) indicates that the parts and/or labor information provided by MOTOR may have been modified or may havQ come from an alternate data source. Tilde sign, (--) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer attermarket parts are described as AM, Qual Repl parts or Comg RRpl Parts which stands for Competitive Replacement Parts. used parts are described as LxQ, Qual Reey Carta, RCY, or USED. IteCvnditioned parts are described as Record. Recored parts are described ass Reeoze. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications; Labor operation times listed on the lin® with the NAGS information are MOTOR suggestQd labor operation cimos. NAGS labor operation times are not included. Pound sign (a) items indicate manual entries. SoAle 2006.vQhicles contain minor changQs from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from [he 1?xevious 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 DathwaYS - A product of CCC Information ServicQS Inc, 2 - Mar, bs 2008 3:58PM State Farm Insurance Steve Buchheit 1880 JPK Road pubuqu0, IA 62002 ' l=ax :663-557-1846 Ph : 563-688-1487 ~'-~S'7 ~,,~t ~ 1 ~e -e K To: h Fax: PFwtu: f~ ~~ Date: No, 9503 P, 1 /_ r Res 3 - 3 ~ IFS /..e g W..`f << ~ ~ CCs .. . :~~ /e~ ^ Urg~t D•F Reviwv Mps~ Ce1~MN1t • ~ Plss~ itaph- D Plotso Rac~rcle . • Co:t~:t:spt:::