Claim Lampe, Lynn E.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 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: Lynn E. Lampe
2. Address: 116 W. 13th Dubuque, IA 52001
3. Telephone Number: Day 563 580 5264 or nite 563 556 2264
4. Date of Incident: 3/04/2002
5. Time of Incident: 13:01
6. Location of Incident (Be specific): Intersection of Dell and Arlington
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.)
I was going north on Dell and a city Truck driven by Robert Schiel was backing up toward East and vehicles collided.
8. What were weather conditions like? cloudy, but clear
9. Give name and address of any witnesses: N/A
10. Did police investigate? (If so, give names of officers.)
Yes, Tom Pregler
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
Yes
13. What other damages do you claim, if any?
2 Hr. of my time for estimates $30.00
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.)
No
15. What amount do you claim from the City of Dubuque? $862.89 to fix jeep plus $30.00 for my time total $892.89
16. Why do you claim the City of Dubuque is responsible? Failure to yield right a way Robert Schiel was ticketed.
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
No
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
No
Dated at Dubuque, Iowa this 5th day of March , 2002.
/s/ Lynn E. Lampe
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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:
2. Address:
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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.) ~ ,~1-{
8. What were weather conditions like?
9. Give name and address of any witnesses:
10. D!d;police investi~jate? (If so,clive names of officers.)
-
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
//~/O
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?
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
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 ~-T~ day of
(Rev. 1/00 & 7/01)
,20
(Signature)~ ~
(Print Name)
�1
Driver Information Exchange Report
Driver's Name - Last
u LAMPE
N Address
116W13THST
T
001
First
LYNN
Dubuque Police Department
(319) 589.4410
MGddle
EDWARD
Suffix Date of Birth
lei
DUBUQUE
State
IA
Zip.
52001
Phone
Gender , Drivers License Number I Class
Male i C,M
state
Endorsements I Restrictions
NONE NONE
Owner Company Name
Insurance Co. Name
STATE FARM
Insurance Policy #
1530245-F16-150
Ittsslran�e Co. Phone
(563) 582-1856 x
Ovner's Name - Last
LAMPE
First
LYNN
Middle
EDWARD
Suffix
Address
11Q W 13TH ST
VIN No.
1J4GZ:78Y1 RC271470
License Plata
872JEA
Year
1994
State
IA
Make
JEP
Year
2003
'city
DUBUQUE
Mode!
GCH
Most Damaged Area
Stale i Zip
IA
62001-
HStyle
MV
Vehicle Configuration
Approximate Cost to Repair or Replace
Q750.00
Di,.ret a Name - Last
u SCHIEL
N
T
002
Address
15 W 28TH ST
First
ROBERT
C,endgr Number Class
Male f3
Ovvner Camriny Name
CITY OF DUBUQUE
State
IA
Middle
JOHN
City
DUBUQUE
State
IA
Endorsements I Restrictions! insurance Co. Name
NONE j NONE SELF INSURED
Insurance Policy a
Zip
52001
Phone
Insurance Co. Phone #
Owner's Name - Last First , Middle,
I
Suffix
Address
5 KERPER
DUBUQUE - IA
62001-
VIN No. : Year
426004698 i 1997
Make Model
CHEV TRUCK
Style I Vehicle Configuration 1
1 06
License Plate #
84636
State • Year I
- Most Damaged Area I Approximate Cost to Repair or Replace
IA 2002 : 06 - Rear , $100.00
County 'Accident occurred within corporate limits of (city)
Dubuque - 31 !Dubuque - 2100
Literal Description
"NIA"
X-Coardirrate 1 Y-Coordinale
"N/A" 1 "N/A"
If accident 000urred outside of city
limits show general vacintty: "NIA"
Direction
"NIA" of
I Nearest City I Route (Cardinal)
-NIA" 1 Travel Direction "NIA"
1; On Road, Street, or Highway:
ARLINGTON
Al Intersection with:
I DEL&
I Distance Direction
"NIA" "NIA" and
Distance
"NIA"
Direction 1 Milepost Number
"NIA" ❑f "NM" Or
Definable intersection, bridge, or railroad crossing
"Iti .A"
Officer
PREGLER, TOM
Badge No. . Law Enforcement Case Number Date of Accident Time of Accident
066 ! 02-1301 - = 03/04/2002 13:01 Hrs,
Printed At: Dubuque Police Department
Page
Case #: 02-1261
Date: 3/4/02 03:13 PM
Estimate ID: 6174
Estimate Version: 0
Preliminary
Profile ID: Mitchell
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQIJE, IA 52001
(563) 583-9121
Fax: (563) 556-4482
Tm(ID: 42-0400210
Damage Assessed By: JOHN KLOTZ JR.
Deductible: UNKNOWN
Owner LYNN LAMPE
Addreas: tt6 W 13TH DUBUQUE, IA 52001
Telephone: Home Phone: (563) 580-9264
Mitchell Service: 916523
Description: 1994 Jeep GrandCherokee Limited
VIN: 1J4GZ78Y¶ RC271470
Mileage: 143,978
Color: BLUE
Drive Train: 5.2L Inj 8 Cyl 4WD
License: 872JEA
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Unite
AUTO BDY OVERHAUL
629849 BDY REMOVEfREPLACE
AUTO REF REFINISH
AUTO BDY REMOVE/REPLACE
629870 BDY REMOVE/REPLACE
602300 BDY REMOVE/REPLACE
AUTO REF ADD'L OPR
AUTO ADD'L COST
AUTO ADD'L COST
FRT COVER ASSY
FRT BUMPER COVER
FRT BUMPER COVER
FRT ADD W/FOG LAMPS
R FRT BUMPER IMPACT STRIP
L PARK/MARKER LAMP ASSEMBLY
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
4713456
55032264
56OO51O5
2.t #
425.00 INC #
C 2.1
0.3
49.60 INC #
32.35 INC #
0.8
75.40 *
2.61 *
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
I. Labor Subtotals
Body
Refinish
Labor Summary
Add'l
Labor Sublet
Units Rate Amount Amount Totals
2.4 45.00 0.00 0.00 105.00 T
2.9 4~.00 0.00 0.00 135.50 T
Taxable Labor 238.50
Labor Tm( ~ 5.000 % t4.31
5.3 252.81
IL Part Replacement Summary
Taxable Parts
Sales Tax ~
Total Replacement Parts Amount
6.000%
Amount
501.95
30.12
53?_O7
ESTIMATE RECALL NUMBER: 3/4/02 14:55:00 6174
UlttaMete is a Trademark of Mitchell International
Mitchell Data Version: FEB 02 A Copyright (C) 1994- 2000 Mitchell International
UitraMate Version: 4.7.0O7 All Rights Reserved
Page t of 2
IlL A~ditioual Costs
Non-Taxable Costs
Total Additional Cc~ds
Date: 3! 4/02 03:t3 PM
Estimate ID: 6174
Estimate Version: 0
Prelimina~
Profile ID: Mit~he0
Amount IV. Adjustments
78.01 Customer Responsibility
78.0'J
Amount
0.00
I. Total Labor:
II. Total Replace~nent Parts:
IlL Total Additional Costs:
Gross Total:
IV. Totsi Adjus'mtente:
Ne~ Tot;d:
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
PA~TS PRICES A~E SUBJECT TO CH~N~
~.o7
78.01
862.89
ESTIMATE RECALL NUMBER: 3/4102 14:55:00 6174
UitraMate is a Trademark of Mitchell International
Mitchell Data Version: FEB_02_A Copyrigl~ (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.7.007 A0 Rights Reserved
Page 2 of