Claim by Noel PloesslC~C~. ~ ~ ~~ ~'~~
~'~~~~~~IM AGAINST THE CITY OF DUBUQUE, IOW
~,
i~8 ~~~ ~ ~ ~'r~f~vr~~en report constitutes your claim against the City of Dubuque, Iowa: Y u
sh u ~ complete this form in full and attach any additional information that
,., . ,~
City` ~.•,~-~t"~ 'your claim.
tJUJU~'..'`'. I,-
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: /V ~J~'
/ G~ /~.`~
' 2. Address: ~ ~~(r ,~'J (~~r1 ~~c~:~ ~i,'L'
3. Telephone Number ~ J~~, ~L&J y~
4. Date of Incident: ~ Z /~. ~~ /~~~L~~
5. Time of Incident: ~ • ~'°~'' /// I
6. Location of Incident (Be spe~ic):
7. Describe the accident or occurrence that caused injury or damage. (Give full
details upon which you bast your claim. If a City employee was involved, give
the employee's name.) _ _ _ _ _ _
8. What~ere we ther conditions like?
9. Give name a.nd~ddress of any witnesses: __
~/ r
10. Did olice inv ti ate? If so, ive ames of officers.
11. Was anyon injured? (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.) (//~/~ c / i `~/ ~j ,f ~
ii 1~/~ /7
13. /W~ hat oth damp a~es do you clan, 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.)
tI
15. Wh t amount do you c im from the City of Dubuque?
16. Wh do you clad they City of Dubuque is responsibl
~yJ~'~ L /'9~/Ui~C CGf~r`.SC•~ 7~`Icr ~ a
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 this ,G ~ day of ~c~G. _ ~ 20~•
,~~/ ~ ~~
~~
(Signature)
~~~ ~ ~~i~s~~
( r-int Name)
Driver Information Exchange Report
1 Dubuque Police Department
563-589-4410
ff
S of Birth
D
t
Driver's Name -Last First Middle ix
u a
e
U MCCLEAN KENNETH JOHN 06/30/1953
City State Zip Phone
N Address
DUBUQUE IA 52001 (563) 556-1980 x
1451 AUBURN ST
I Insurance Co. Phone #
Gender Driver's License Number Class State Endorsements Restrictions Insurance Co. Name
IOWA COMMUNITIES (563) 589-4120 x
T Male 946AA2817 A IA N-L NONE
001 Owner Company Name Insurance Policy #
CITY OF DUBUQUE
Owner's Name -Last First Middle Suffix
Address Ci
tY
DUBUQUE State
IA Zip
52001-
i 50 W 13TH ST
Year Make Model Style Vehicle Configuration
VIN No
.
1 HTWDAAN46J255822 2008 INTL 7400 SFA 4X2 PK 21
License Plate # State Year Mast Damaged Area Approximate Cost to Repair or Replace
84557 IA 2099 05 -Rear 50.00
f Birt h
Driver's Name -Last First Middle Suffix Date o
U
N
Address
City
State
Zip
Phone
I
Gender
Driver's License Number
Class
State
ments
ons
t
ND ame (563) 558-1499 xe
IW
c
T NONE NE
NO BE
EST
002 Owner Company Name Insurance Policy #
HHI534187709
Owner's Name -Last First Middle Suffix
PLOESSL NOEL FRANCIS
Ci State Zip
2762 CARLTON ST DUBUQUE IA 52001-
VIN No Year Make Model Style Vehicle Configuration
.
1FTPX14586NA02533 2006 FORD XXX PK 02
License Plate # State Year Most Damaged Area Approximate Cost to Repair or Replace
200AVX IA 2008 07 -Left Side 51,500.00
County Accident occurred within corporate limits of (city)
Dubuque-31 Dubuque-2100
Literal Description
CARLTON ST
X-Coordinate Y-Coordinate
00688437 04707396
If accident occurred outside of city Direction Nearest City
"
" Route (Cardinal)
Travel Direction SB
limits show general vacinity: "N/A" "N/A" of N/A
On Road, Street, or Highway: At Intersection with:
CARLTON ST "NIA"
Distance Direction Distance Direction Milepost Number
400 Ft 6-SW and "N/A" "N/A" of "N/A" Or
Definable intersection, bridge, or railroad crossing
BROWN ST
Officer Badge No. Law Enforcement Case Number Date of Accident Time of Accident
WALKER MATTHEW 70 01-08-59017 12/26/2008 01:00 Hrs.
Printed At: Dubuque Police Department 12/28/2008 03:18 AM Page 1 Form #: 01-08-59017
' TOYS DONE RIGHT
1006 central ave
DUBUQUE, IA, 52001
Te1:563-552-1601 Fax:563-552-2207
Tax ID:26-1404014
Estimate -Preliminary
Estimate Prepared by:
Accident Date:
Date of Loss:
Arrival Date:
Type of Loss:
Policy Number:
Claim Number:
Owner:
Appraised for:
Date: 12/26/2008
Estimate#:
Contact: Noel Ploessl
Address: 582-6740 work
Year Make Model Color Trim
2006 Ford Pickup XLT Extended Cab Pickup
Unit Number License Plate # Mileage Serial#/VIN#
IFTPX14586NA02533
Sup Seq Qty Labor Labor Description Part Part List Extended Labor
Type Op Type Number Price Price Units
1 1 Ref Ref Refinish Fender Exist 2.2
Outside L
2 1 Body Repair Fender From 8-9-OS Exist 1 •~
2006 w/o Wheel
Opening Mldgs L
3 1 Body Rem/Rep R&I MUD FLAPS New •5*
ON LT SIDE
4 1 Ref Ref Refinish Door Exist 2.8
Outside Extended
Cab L
5 1 Ref Ref Refinish Door Exist •5*
Outside Add for
Jambs & Interior L [
SPOT IN]
6 1 Body Repair Shell Assy, Door Exist 4.0~
2005-08 Extended
Cab L
7 1 Ref Ref Refmish Door Exist 2.1
Outside L
8 1 Ref Ref Refinish Door Exist 1.0
Outside Add for
Jambs & Interior R L
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Sup Seq Qty Labor Labor Description Part Part List Extended Labor
Type Op Type Number Price Price Units
9 1 Body Rem/Rep Panel, Door Repair New 4L3Z $279.98 T $279.98 5.5#
2005-08 Panel, Door 1824701
Repair L CA
10 1 Body Rem/Rep Panel bonding New $25.00 T $25.00
materails
11 1 Body Rem/Rep R&I LT Door Handle New .5*
12 1 Body Rem/Rep R&I LT Vent visors New 1.0*
13 1 Ref Ref Refinish Outer Panel Exist 3.0
6 Foot Bed L
14 1 Body Repair Panel, Outer Side w/o Exist 3.Oi#*
Wheel Opening
Mldgs 6 Foot Bed L
15 1 Body Rem/Ins Moulding, Bed Rai16 Exist .4
Foot Bed Black 2006
L
16 1 Body Rem/Rep R&I tool box New .5*
17 1 Body Rem/Rep Decal, Bed Side New 4L3Z $43.22 T $43.22 .2
Shadow Gray w/o 9925622
60th Anniversary EAB
"4X4" L 07-08
18 1 Body Rem/Ins R&I Combination Exist .2
Lamp L
19 1 Body Rem/Ins R&I Reaz Bumper Exist .4
20 1 Body Rem/Rep Mirror Assy, Rear New 6L3Z $205.80 T $205.80 .3#
View (Factory 17683 CA
Installed) Black w/o
Puddle Lamp 2006
Heated Power L
21 1 Body Rem/Rep Rust Proof New $15.00 T $15.00 .5*
22 1 Ref Ref Cleaz coat Exist 2.0*
23 1 Body Rem/Rep Cover for over spray New $10.00 T $10.00 .2*
24 Paint Materials $476.00
* -Judgement Item
# -Labor Note Applies
Labor
Body 18.2 Hrs @ $55.00
Refinish 13.6 Hrs @ $55.00
Labor Total
$1,001.00
$748.00
$1,749.00
Parts
Parts Subtotal
Less Adjustments
Parts Total
Additional Costs and Operations
Addl. Costs/Ops Total
Tax
$579.00
$476.00
Labor Tax @ 7.00% $122.41
Parts Tax @ 7.00% $40.53
Tax Total $162.94
Totals
2006 Ford Pickup XLT F150
$579.00
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Sub Total: $2,966.94
- ~ Customer Resp. $0.00
Net Total 52,966.94
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
e 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.
2006 Ford Pickup XLT F 150
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