Claim, Schultz, Marisa- fl?R~tS-02 'IIJE 09:20 tim D~U6Li'E OIT70LERK F¢_× NO. 56:3 589 0890 P. 01/02
CLAI AGAINST THE CITY OF DUBUQUE, iOWA /~/z~//~
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 tS 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.
3. Telephone Number=
4. Date of Incident:
5. Time of Incident: ~,;~0 .¢r'~
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. Ifa City employee was involved, give the
e.mployee's name~)
8, What were w.the~ condit,ons Dike? ~
9. Give name and a~ress of any witnes~s:
10. Did l~lice in~v.~s, tjglate? (If so, give names of officers.)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
P.'O. I~0× 875'
(563) 589~[5 dij~atch
(563) 589-443.0 ~ce
04116/02 10:
~PR-16-¢2 TUE 09t21 fl~ D~U~U£ CITY OLERK F~× NO. 58~ 588 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 ~[o 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.)
What amou.t do you claim the City of
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 day o~ ~ , 20~)~- .
~ (Print Name)
(Rev. 1/00 & 7101)
04/16/02 10:27 TX/IIX N0.4378 P.002 ·
Date: 5/6/02 04:31 PM
Estimate ID: 3t45
EstimateVersion: 0
Preliminary
Profile ID: Mitchell
Dan Kruse Pontiac, Nissan, BMW
600 Century Drive Dubuque, IA 52002
(563) SS~-7~S
Fax: (563) 588-3874
Insured: MARISSA SCHUL'rZ
A~ress: 2A44.S BROADWAY DUBUQUE, IA 52001
Telephone: Home Phone: (563) 582-1201
Description: 20~0 Pontiac Grand Am SE1
Body Style: 4DSed
VIN: 1G2NF52TgYM762549
Mitchell Service: 910495
Drive Train:
2AL inj 4 Cyl 5M
Line Entry Labor
Item Number Type Operation
I 630190 BDY REPAIR
Line Item
Descdption
Part Typ~
L FENDER PANEL
Labor
1.0'#
2 AUTO REF REF0~SH
3 000846 REF RI~INISH
4 000870 REF REFINISH
$ 00~74 BDY REMOVE/INSTALL
6 000876 NDy REMOVE/INSTALL
7 000896 BDY REMOVE/INSTAU.
8 000963 BDY REMOVE/INSTALL
9 AUTO REF ADD'L OPR
t0 AUTO ADD'L COST
11 AUTO ADD'L COST
L FENDER OUTSIDE
L FRT DOOR OUTSIDE
L FRT LWR DOOR MOULDING
L FRT LWR DOOR MOULDING
L FRT REAR VIEW MIRROR
L FRT OTR DOOR BELT MCAJLOING
L FRT OTR DOOR HANDLE
CLEAR COAT
PAINT/MATER]ALS
HAZARIDOUS WASTE DISPOSAL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
C ?-1
C 1.5'
C
O.3
0.3 #
O.3*#
0.7 #
1.3'
147.50 *
3.50 *
Add'l
Labor Sublet
L~bor Subtotals Units Rate Amount Amount Totals
Body 2.6 40.00 0.00 0.50 1~4.50 T
Refinish 5.5 40.50 0.0o 0.50 236,00 T
Taxable-L=_b,~__. ~40.0~
Labor Tax ~ 6.000 % 20.40
Labor Sum~ 8.5 360.4O
IL Part Replacement Summary
Total Replacement Parts Amount
ESTIMATE RECALL NUMBER: 5/6/02 16:25:0t 3145
I~ltchell Data Version: MAY_02_A Copyright (C) 1994 - 2000 Mitchell International
UItraMate Version: 4.7.007 All Rights Reserved
0.50
Page I of 2
UL Additional Costs
Non-Taxable Costs
Total AddFdonal Costs
Date: 5/6/0204'.31 PM
Es~mate ID: 3145
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Amount IV. Adjustments
151.00 Customer Responsibility
151.00
Total Labor:.
Total Ad~ional Coasts:
Gross Total:
360.4O
151.00
511.40
IV. Total A~ustments:
Ne~ Total:
This is a preliminaw estimate.
Additional chanues to the estimate may be required for the actual re.pair.
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER ANY ADDIONAL PARTS OR LABO~
T~ WOrK HAS ]~N OPENED UP ~ INS,WILL BE NOTIFIED.
WE FEATURE A THREE YEAR WORKMANSHIP LIMITED WARRANTY- SEE OUR NRITTEN
WARRANTY FOR COMPLETE DETAILS. (EFECTIVE 10-01-01)
0.00
$11A0
DAVE DeMOSS
Body Shop Manager
I
DAN I(RUSE PONTIAC-NISSAN, INC /
600 Centu~, Drive Bus. (563)~83-7345
Dubuque, Iowa 52002 Toll Free 14~00-373-CAR5
ESTIMATE RECALL NUMBER:.. 5/6/02.t6:2r~'04. 3145
U#raMate is a Tredemark of Mitchell International
Mitchell Data Version: MAY_02_A Copyright (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.7.007 ~JI Rights Reserved
Page 2 of 2
FED ID #42-0813744
Da~e: 5/6/02 04:48 PM
Estimate ID: 6400
Estimate Version: 0
Preliminer/
Profile ID: CUSTOMIZED
Damage Assessed By: AL COGHLAN
De~luctible: UNKNOWN
RICHARDSON MOTORS
1475 J.F.K. ROAD DUBUQUE, IA 52002
(563) 582-5411
Fax: (563) 582-4129
Owner MARISSA SCHULTZ
Addr~: 2444/5 BROADWAY DUBDQUE, IA 52001
Telephone: Home Phone: (563) 582-1201
Mitchell Service: 910495
Description: 2000 Pontfac Grand Am SE1
VIN: 1G2NF52TgYM762549
IRiChardsonl
Buick Cadillac GMC Tzuck Honda j
Al Coghlan
Body Shop Manager
Business (319) 582-5411 Fax (319) 582-4129
1475 John F. Kennedy Rd. Dubuque, Iowa 52002
Toll Free: 888-806-5411
Dr
Ur~ Entry Labor
Item Number Type OperaUon
I 000190 BDY REPAIR
2 AUTO REF REFINISH
3 000846 REF REFINISH
4 000870 REF REFINISH
5 000874 BOY REMOVE~N~TALL
6 000906 BDY REMOVE/INSTALL
7 000993 BOY REMOVE/INSTALL
8 AUTO REF ADIYL OPR
9 AUTO ADD'L COST
10 AUTO ADD'L COST
Line Item
Description
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
Part Type/ Dollar Labor
Part Number Amount Units
Existing
Existing
1.0'#
C 2.1
C t.8
C 1.0
0.3
0.7 #
1.4
163.80 *
6.00 *
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
I. Labor Subtotals Units Rate
Body 2.3 42.00 0.00
Refinish 6.3 42.60 0.00
Add'l
Labor Sublet
Amount Amount
Taxable Labor
Labor Tax ~ 6.000 %
Labor Summary 8.6
ESTIMATE RECALL NUMBER: 5/6/02t6:43:01 6400
M Jtchell Data Vemlen: MAY_02_A
UltraMate Version: 4.7.007
Totals
0.00 96.60 T
0.00 264.60 T
361.20
21.67
382.87
IL Part Replacement Summary
Total Replacement Parts Amount
UltraMate is a Trademmk of Mitchell International
Copyright (C) 1994- 2000 Mitchell InternaUonal
All Rights Reserved
Page I
Amount
0.00
of 2
Date: 5/6/02 04:48 PM
Estimate ID: ~0
Estimate Version: 0
Prelimin~y
Profile ID: CUSTOMIZED
IlL - Additional CeSts
Ta~ble Costs
Sales Tax
Non-Taxable Costs
Total Additional Costs
6.00~/o
Amou~
6.00
0.36
170.46
IV. Adjustments
Customer Responsibility
I. Total Labor:.
II. Total Replacenlent Parts:
III. Total Additional Costs:
Gross Total:
Amou~
0.00
38?.87
170.t6
553,03
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
A,~I_ ;fi0nal chanties to the estimate may be reuuired for the actual mi)air.
ESTIMATE RECALL NUMBER: 5/6/02 16:43:0~ 6400
UltraMate is a Trademark of MEchell International
Mitchell Data Version: MAY_02_A Copyright (C) 1994 - 2000 Mitchell International
UltraMate Version: 4.7.007 All Rights Reserved
Page 2 of