Claim by Terrell MitchemCLAIM 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 hasthe authority to make any representation to you as to
whether your claim will or will not be paid.
1. Name of Claimant: ~~~~ 1~ ~~G~ ~~'1
2. Address: ~-~~ ~~/
3. Telephone Number S~ 3 r .~~~- ~7T
4. Date of Incident: ~ ~ ~~ `~ ,
5.-Time of Incident:
6. Location of Incident (Be specific): / (~
i ~ ~~ ( ~,~1 ~f -''~
7. Describe the accident or occurrence that caused injury or damage. (Give fuii
details upon which you base your claim. If a City employee was involved, give
the employee's name.).,.; ' _ ,
8. What were weather conditions like?
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9. Give name and add es~ ~ ny witnesses: / ~ __ j, ,^ ~,~
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10. Did police investi ate? (If so, give names of officers.) ~~' ~, ~ ~-.'~~
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11. Was anyone i^~jured? (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?
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 r_.ompany and
amount paid.)
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15. What mount do you claim from the City of Dubuque?
16. Why do you claim the City of Dubuque is responsible?
. .___ ~ ~~._t_
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17. Have you madean~ i/laim against anyone else for damagesas 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? ~ ,r,
Dated this ~~~~ 'day of L~ _ , 20 C ~.
(Signature - r
~`5 "~ / t ''~ n ~ f, ,y ,
t'/`~~~ 1 ~~ ~ lit ~ 1 ~l ~'
(Print Name)
Date: 7/11/2008 04:20 PM
Estimate ID: 7925
Estimate Version: 0
Preliminary
Profile ID: Mitchell
~ ~ ~
1 e inn~n or
3600 Dodge Street, Dubuque, IA 52003
(563) 556-1010
Fax: (563)690-1086
Tax ID: 14-1862673
Damage Assessed By: Rick Stumpf
Deductible: 0.00
Claim Number: 7925
Insured: TERRELL MITCHEM
Address: 1551 BLUFF APT3, DUB, IA 52001
Mitchell Service: 915525
Description: 1996 Chrysler Concorde LX
Body Style: 4D Sed
VIN: 2C3HD56T1TH264452
Line Entry Labor
Item Number Type
1 500503 BDY
2 .AUTO REF
3 519600 BDY
4 AUTO REF
5 AUTO REF
6 AUTO
T AUTO
Drive Train: 3.3L Inj 6 Cyl AO
Line Item Part Type/
Operation Description Part Number
REPAIR R REAR DOOR SHELL Existing
REFINISH R REAR DOOR OUTSIDE
REPAIR R QUARTER OUTER PANEL Existing
REFINISH R QUARTER PANEL OUTSIDE
ADD'L OPR CLEAR COAT
ADD'L COST PAINT/MATERIALS
ADD'L COST HAZARDOUS WASTE DISPOSAL
* -Judgment Item
# -Labor Note Applies
C -Included in Clear Coat Calc
Add'I
Labor Sublet
I. labor Subtotals Units Rate Amount Amount
Body 2.0 53.00 0.00 0.00
Refinish 5.5 53.00 0.00 0.00
Taxable Labor
Labor Tax @ 7.000
Labor Summary 7.5
Totals II. Part Replacement Summary
106.00 T
291.50 T Total Replacement Parts Amount
397.50
27.83
425.33
III. Additional Costs Amount IV. Adjustments
Non-Taxable Costs .786.50 Insurance Deductible
Total Additional Costs 186.50 Customer Responsibility
ESTIMATE RECALL NUMBER: 07/11/2008 16:20:15 7925
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUN_08_A Copyright (C) 1994 - 2005 Mitchell International
UltraMate Version: 6.0.030 All Rights Reserved
Dollar Labor
Amount Units
1.0*#
C 2.2
1.0* #
C 2.0
1.3*
181.50
5.00
Amount
0.00
Amount
0.00
0.00
Page 1 of 2
Date: 7/11/2008 04:20 PM
Estimate ID: 7925
Estimate Version: 0
Preliminary
Profile ID: Mitchell
I. Total Labor: 425.33
II. Total Replacement Parts: 0.00
III. Total Additional Costs: 186.50
Gross Total: 611.83
IV. Total Adjustments: 0.00
Net Total: 611.83
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair
ESTIMATE RECALL NUMBER: 07!11/2008 16:20:15 7925
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUN_08_A Copyright (C) 1994 - 2005 Mitchell International Page 2 of 2
UltraMate Version: 6.0.030 All Rights Reserved
HART AUTO BODY & PAINT
800 CEDAR CROSS ROAD DUBUQUE, IOWA 52003
PHONE: (563) 556-8323 FAX: (563) 556-8324
DAMAGE REPORT
PRICES SUBJECT TO CHANGE
Items CIRCLED are not in the total in
our opinion, are not part of this claym.
VEHICLE OWNER ADDRESS PHONE DATE
~wll n-i~~l-ch~M .S`cs-~'1 ~1~K r (- 0
/ MAKE MODEL LICENSE MILEAGE LOR SERIAL NO. CONDITION
k / .f f ~ti L ~
N RANCE CO ADJUSTER PHONE CAR LOCA ED AT DEDUCTIBLE
Syrn. FRONT Sublet
Or Paint Service ;
Or Hours
Parts
Sym. LEFT Sublet
Or Paint Service ;
Or Hours
Parts
Sym. RIGHT Sublet
Or Paint Service ;
Or Hours
Parts
Bumper W/Pads 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 Mldg.
Bumper Reinf.
Bumper B-kt. Side Light Asmbly Side Light Asmbly
Bumper Cushion Headlamp Headlamp
Valance Headlamp Door Headlamp Dr.
Bumper Gd. Sealed Beam Sealed Beam
Frt. System Park Light Park Light
Frame Cowl Cowl
Cross Member Door. Front Door, Front
Wheel Door Hinge Door Hinge
Hub CaD Disc Door Panel Door Panel
Lr. Cont. Arm Door Stripe Door Stripe
Door Mldgs. Door Mldg.
Up. Cont. Arm
Center Post Center Post
Door Rear Door Rear fl
Bumper Filler Door Midg. Door Mldg.
Grille
Grille Panel
Grill Panel Mldg. Rocke- Panel Rocker Panei
Rocker Midg. Rocker-Mldg.
Floor Floor
Dog Leg Dog Leg
guar. Panel guar. Panel ~
Air Condenser guar. Ext. guar. Ext.
Recharge System guar. Wheel House guar. Wheel Hourg
Name Plate guar. Mldg. Side guar. Midg. Side
Baffle, Upper guar. Mldg. guar. Mldg.
Lock Plate, Lr. guar. Stripe guar. Stripe
Lock Plate, Up. Side Light Asmbly Side Light Asmbly
Hood Top Tail Light Tait 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 Filter Tire % Worn
Fan Shroud Valance Painting
Fan Belt Lower Panel Aerial J~~ -r% ~ O
Water Pump Floor Rust Proof
Water Pump Pulley Trunk Lid Battery
Motor Mts. Trunk Midg.
EPA WASTE DISPOSAL CHARGE f D ~
Lic. Light PARTS (Prices Subject To Invoice)
b
-- '' 0
~
SERVICES HRS. Q,3
D HR. r
Windshield Gas Tank SUBLET OR PAINTING
Frame SUB TOTAL ~. ~
wheel TAX .r. ,Za
Hun & Drum PAINT
MATR Z
O
B
-
L-HDW. o
,
•
_ Axle
Spring
GRAND TOTAL ,r '~
Appraiser
Symbols:
A-Align N-New OP-0pen P-Paint I HEREBY AUTHORIZE THE ABOVE REPAIRS
S-Straighten R-Replace OH-Overhaul
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