Claim Schultz, MarissaCLAIM 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: Marissa Schultz
2. Address: 2444 1/2 Broadway Dubuque IA 52001
3. Telephone Number: 563 582 1201
4. Date of Incident: 4-13-02
5. Time of Incident: 3:30 p.m.
6. Location of Incident (Be specific): 18th & Central
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.)
The Power had gone out downtown and therefore the stoplights weren'tworking. There were stop signs put up instead. I was stopped at the intersection and the stop sign blew over and hit my car.
8. What were weather conditions like?
Clear & gusty
9. Give name and address of any witnesses:
No witness stopped
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Abitz
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, dented by Windshield drivers side scratchedmouling, chipped & scratched paint
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.)
No
15. What amount do you claim from the City of Dubuque?
$511.40
16. Why do you claim the City of Dubuque is responsible?
The stop sign belonged to the City.
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?
Dated at Dubuque, Iowa this 10 day of May , 2002.
/s/ Marissa Schultz
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
¢~?R-I6-02 TUE 09:20 ~ DLIBUgliE 0IT¥ 0LERK FRR lqO, 56:3 588 {3890 ?, 01/02
o,.,,,,,, A,,,,,,,,ST',-.,:, o,: ,:,,.,,,,.,,=,,..,,'.
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. 13u~ 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.
!. Name of Claimant: (~J~i.._.~.
:L Telephone Number: ~(J2~%~;~~
4. Date of Incident: H-i502 ...
5. Time of Incident: ¢;~0 .¢t'~
6. Location of Incident (Be specific):, l~
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
e.rnployee's name~) ' /~
8. what we~ w~ther conditions like?~! ~
9~ Give name and address of any w~nesses: ~(~ ~_~l~,~_~ ~
10. Did i~li~e inyeAs, t;igate? (If so, give names of officers.)
11. Was anyone iniured? (If so, give names, addresses, and extent of injuries),
04/16/02 10:27 TX/RX N0.4378 P.001 ·
AP~-lS-02 TOE 09;2t ~ 1)~JB~J~JE OIT¥ OLE~I( FC~X XO, 563 589 0890 P. 02/02
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 you; claim by any insurance
company? (if so, give name and address of insurance company and amount paid.)
what amount de ye- claim t,, City of
16. Why de you claim the City o! 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 J 0 . ., 20~)~ .
day ct ~
(Signature) o
(Print Name)
(Rev. 1100 & 7101)
04/16/02 10:27 TX/RX N0.4378 ?.002 ·
Dubuque Police Deparhnenl
Law E~aforcement Center
~O. Box 875*
Dubuque, Iowa 5200~-0875
(563) 5894~15 ctispatch
(563) 5892.410 office
911 Emergency
Date: 5/6/02 04:31 PM
Esl~mte ID: 3145
EstimateVersion: O
Prelil~na~y
pfol~e ID: Mitchell
IIL
Non-Taxable Costs
1,51.00
IV. Adjustments
customer ~espons]biiity
L TMal Labor:,
IL Total Replacement Parts:
m. Total Additional Costs:
Gross Total:
Amount
0.00
360.4O
0.00
151,00
511.40
IV. Total Adjustments:
Net Total:
$11A0
This is a preliminary estimate.
Additional chanqes to the estimate may be reuuimd for the actual repair.
· £~£S DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER AN~ ADDIONAL PARTS OR LAB~ ~=TICH_MAY_ BE_ P~EQUIP~E~ AFTER
Tm WORK H~S BEEN OPENED UP '£~ INS,WILL RE NOTIFIED.
WE FEATURE A '£~K~E YEAR WORKMANSHIP LIMITED ~M~ANTY- SEE OUR ~ITTEN
WARP, ANT~ FOR COMPLETE DETAILS. (EFECTIVE 10-01-01)
DAVE DeMOSS
Body Shop Manager
DAN K~USE PONTIAC-NISSAN, INC. 1
600 Centu~/Drive Bus. (563)~83-7345
Dubuque, Iowa 52002 Toll Free 1-80~-373-CARS
ESTIMATE R~cCAU. NUMBER:.. 6/.6/02.16:26:0/3145
UltraMate is a Trademark of Mitchell letemational
Mitche# Data Version: MAY_02_A Copyright (C) 1994 - 2000 Mitchell International
UltraMa~e Version: 4.7.007' All Rights
Page 2 of 2
Date: 5/6/02 04:31 PM
Estimate ID: 3145
EstimateVersion: 0
Prelleduery
Profile ID: Mitchell
Dan Kruse Pontiac, Nissan, BHW
600 Century Drive Dubuque, IA 52002
Fax: (563) 588-3874
Insured: MARISSA SCHULTZ
Address: 2444.5 BROADWAY DUBUQUE, IA 52001
Telephone: HomePhoue: (063)582-1201
M~chellSe~ice: 910495
Descdp~on: 2000 Pontiac Grand Am SE1
Body Style: 4DSed
VIN: 1G2NF$2T~YM762549
Drive Trai.: 2.4L lei 4 Cyl 5M
Une Entry Labor
item Number Type Operation
I 000190 BDY REPAIR
2 AUTO REF REFINISH
$ 000846 REF REFINISH
4 000870 REF REFINISH
0 000874 BDY REMOVE/INSTALL
6 000876 BDY REMOVE/INSTAU.
7 000896 BDY REMOVEANSTALL
8 000993 BDY REMOVE/INSTALL
0 AUTO REF ADD'L OPR
10 AUTO ADD'L COST
11 AUTO ADD~ COST
Line item
L FENDER PANEL
L FENDER OUTSIDE
L FRT DOOR OUTSIDE
L FRT LWR DOOR MOULDING
L FRT LIN~ DOOR MOULDING
L FRT REAR V~EW MIRROR
L FRT OTR DOOR BELT MOULDING
L FRT OTR DOOR HANDLE
CLEAR COAT
PAINT/MATER~RLS
HAZARDOUS WASTE DISPOSAL
Part Type/
Dollar Labor
Amount Units
1.0' #
C 2.1
C 1.5'
C 1.0
0.3 #
0.3*#
O.7 #
1.3'
147.50 *
3.~0'
* - Judgement ~em
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Sublet
L Labor Subtotals Units Rate Amount Amount Totals
Body 2.6 4~0 0.00 0~DO 10400 T
Refinish 5.9 40.00 0.00 0.00 236.00 T
Labor Tax ~ 6.000 % 20.40
Labor Sunmmry 0.5 360A0
II. part Replacement Summary
Total Replacement Parts Amount
ESTIMATE RECALL NUMBER: 5/6/02 16:25.01 3145
UltraU-~A ~s a-T'~"k~k of u ~,,u InterueUonal
MitchMI Data Version: MAY_02_A Copyright (C) 1994 - 2000 Mitchell letema~onal
DitraMate Version: 4.7.007 All Rights Reserved
Page I
of 2
IlL Additional Costs Amount
Non-Taxable Costs
Total AclcFd~onal Costs 15
Date: $16/0204:31 PM
Estimate ID: 3145
Estimate Version: 0
Preliminary
Pro~le ID: Mitchell
Amount
0.0O
L Total Labor.
It. Total Replacement Par~s:
IlL Total Additional Costs:
Gross Total:
360A0
0.00
151.00
511.40
IV. Total Adjustments:
Ne~ Total:
0.00
511.40
This is a preliminary estimate.
Additional chanaes to the estimate may be required for the actual repair.
THIS D~/AC~ REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER ANX ADDIONAL PARTS OR LABO~ WHI~H_MA~ BE_ REQUIREII AFTER
T~ WORK HAS BgkN OPENED UP T~ INS,WILL BE NOTIFIED.
WE FEATORE A THREE YEAR ~SHIP LIMITED ~RANTX- SEE OUR WRITTEN
~ARRANTY FOR COMPLETE DETAILS. (EFECTIVE 10-01-01)
DAVE DeMOSS
Body Shop Manager
DAN KRUSE PONTIAC-NISSAN, INC. 1
600 Cenlur~, Drive Bus. (563)~83-7345
Dubuque, Iowa 52002 TolJ Free 14300-373-CARS
ESTIMATE RECALLNUMBER:. ra/.6/02.16:25:Ot 3145
IU~'aMate is a Trademark of Mitchell Intmlkqtiond
Mitchell Da~ Version: MAY_02_A COpyright (C) 1994 - 20~0 Mitchell International
UltraMate Version: 4.7.007 Ali Rights Reserved
P~ge 2 o~ 2
FED ID #42-0813744
Date: 5/6/02 04:48 PM
Estimate ID: 6400
Estimate Version: 0
Prsfiminary
Profile iD: CUSTOMIZED
Damage Assessed By: AL COGHLAN
Deductible: UNKNOWN
RICHARDSON MOTORS
t475 J.F.K. ROAD DUBUQUE, IA 52062
(563) 582-5411
Fax: (563) 582-4t29
Owner MARISSA SCHULTZ
Address: 244415 BROADWAY DUBUQUE, IA 52001
Telephone: Home Phone: (563) 582-1201
Mitchell Service: 910495
Description: 2000 Pontiac Grand Am SEt
Body Style: 4DSed
VIN: IG2NF52T9YM762~49
IRichardso-
Buick Cadillac GMC Truck Honda J
Al Coghlan
Body Shop Manager
Business (319) 582-5411 Fax (319) ~82-4129
1475 John F. Kennedy Rd. Dubuque, Iowa 52002
Tell Free: 888-806-5411
D~
Line Ent~ Labor
Item Number Type Operation
Line Item
Description
I 000190 BOY REPAIR
2 AUTO REF REFINISH
3 000846 REF REFINISH
4 0O0870 REF REFINISH
~; 000874 BDY REMOVE/INSTALL
6 000906 BDY REMOVE/INSTALL
7 000993 BOY REMOVE/INSTALL
8 AUTO REF ADD'L OPR
9 AUTO ADD'L COST
10 AUTO ADD'L COST
L FENDER PANEL
L FENDER OUTSIDE
L FRT DOOR OUTSIDE
L FRT LWR DOOR MOULDING
L FRT LWR DOOR MOULDING
L FRT DOOR REAR VIEW MIRROR
L FRT OTR DOOR HANDLE
CLEAR COAT
PAINT/MATERiALS
HAZARDOUS WASTE DISPOSAL
Pa~ Type/ Dollar Labor
Part Number Amount Units
Existing
Existing
t.0'#
C 2.1
C t.8
C t.0
0.3
0.3*#
0J #
tA
t63.80 *
6.00 *
* ' Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals
Body 2.3 42.00 0~)0 0.00 96.60 T
Re~intsh 6.3 42.00 0.00 0.00 264~60 T
Taxable Labor 36t.20
Labor Tax ~ 6.000 % 21.67
Labor Summary 8,6
ESTIMATE RECALL NUMBER: 5/6/82 16:43:01 6400
Mitchell Data ve~ion: MAY_O2_A
UIt~Ma~e Version: 4.7.007
382.87
Part Replacement SemmMy
Total Replacement Parts Amount
UItraMate is a Trademark of Mitchell Int~mationM
Copyright (C) 1994- 2000 Mitchell InternaUonel
All Rights Reserved
0.00
Page t of 2
Date: 5/6/02 04:48 PM
Estimate ID: 6400
Estimate Version: 0
Prelimirrary
Profile ID: CUSTOMIZED
III. Additional Costs
Taxable Costs
Sales Tax
Non-Taxable Costs
Totsl Additional Co/sts
Amou~
0.36
163.80
t70.16
IV. Adjustments
Customer Responsibility
0.00
L Total t.a~.
IL TOtal Replacement Parts:
IlL Total Mdttiomll Costs:
Groes Total:
382.87
0~00
t70.16
SS3.03
IV. Total Adjustments:
~ Total:
553.03
This is a oraliminary estimate.
Additional chanaes to the estimate may be reauired for the actual repair.
ESTIMATE RECALL NUMBEI~ 5/6/02 16:43:01 6400
UlbaMate is a Trademark of Mitchell International
Mitchell Data Version: MAY_02_A Copyright (C) t994 - 2000 Mitch~# International
UltmMate version: 4.7.007 All Rights Reserved
Page 2 of 2