Claim by Leonard W. Dress, Jr.,_ ~ ~-
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AINST THE CITY OF DUBU UE IOWA ~!~~~!~~~~
CLAIM AG Q ~~
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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 has the authority to make any representation to you as to
whether your claim will or will not be paid.
1. Name of Claimant: ~ L° ~ ~ c! f/' C~ ~N
2. Address:
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3. Telephone Number ~ ~o ~ _ ~ '~~~_~~~ ~
4. Date of Incident: f'/ ~ ~ .,L to -~
5. Time of Incident: ~ ,` ~ ~ ~~
6. Location of Incident (Be specific):
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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
9. Give name and address of anu-witnesses: _
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10. Did police investigate? (If so, give names of officers.)
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8. Wh t were v~eather conditions like?
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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13. What other damages do you claim, if any?
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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.)
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15. What mount do yo~lairp from the City of Dubuque?
16. Why do you claim the~City of Dubuque is respg~sible?
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17. Have you made any claim against anyone else for. damages as a result of
this incident? (If yes, give name and address.)
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 dama e )
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
Dated thi ~ day of ~c~~t~ ~ ~
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, TOYS DONE RIGHT
1006 central ave
DUBUQUE, IA, 52001
Te1:563-552-1601 Fax:563-552-2207
Tax ID: 131-023992
Estimate -Preliminary
Estimate Prepared by:
Accident Date:
Date of Loss:
Arrival Date:
Type of Loss:
Policy Number:
Claim Number:
Owner:
Year Make
2002 Chevrolet
Unit Number License Plate #
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Appraised for:
Date: 8/27/2008
Estimate#:
Color ~ Trim
Contact: Leonard Dress
Address: 556-8717
Model
Impala Sedan
2G1 WFSSE029383756
Li Extended Labor
Price Price Units
2.8
1.6#
4.0~*
Sup Seq Qty Labor Labor Description Type Number
Type Op
1 1 Ref Ref Refinish Front Cover Exist
2 1 Body Rem/Ins R&I Front Bumper Exist
Assy
3 1 Body Repair Cover, Front (P) Exist
wBody Side Mldg
Base Model w/o
Appearance Pkg
4 1 Body Rem/Rep Deflector, Lower Rad New 10436318
Air
5 1 Ref Ref clear coat Exist
6 Paint Materials
* -Judgement Item
# -Labor Note Appl ies
$59.87 T $59.87 •2
.5*
$105.60
Parts
Labor parts Subtotal
Body 5.8 Hrs @ $52.00 $301.60
Refmish 3.3 Hrs @ $52.00 $171.60 Less Adjustments
$473.20 Parts Total
Labor Total
Additional Costs and Operations
Addl. Costs/Ops Total
Taz
$59.87
$59.87
$105.60
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Database Edition CPL 08-07
Labor Tax @ 7.00% $33.12
Parts Tax @ 7.00% $4.19
Tax Total $37.31
Totals
Sub Total: $675.98
Customer Resp. $0.00
Net Total $675.98
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
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 marry business repair partners. This application
allows the author to manually enter line items such as overlap deductions.
2002 Chevrolet Impala
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Database Edition CPL 08-07 Page 2 of 2