Claim Heri (Sawvell) MonicaCLAIM 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: Monica (Sawvell) Heri
2. Address: 2339 Poplar St. Dubuque Iowa 52001
3. Telephone Number: 582 5416
4. Date of Incident: July 17, 2002
5. Time of Incident: 8:10 A.M.
6. Location of Incident (Be specific): 2339 Poplar St. - car was parked in front of my house.
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.)
Thomas Thurston was backing up the trash truck that he was driving, after picking up trash and needing to now go down the alley. He hit my van with the back corner of his truck causing damage to the bumper; 1/4 panel and driver's door.
8. What were weather conditions like?
Warm summer morning - dry pavement
9. Give name and address of any witnesses:
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Andrew Harden #59A
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.)
The drivers side was hit. Damage to front bumper, quarter panel and drivers side front door, unable to fully open front door (2 estimates enclosed)
13. What other damages do you claim, if any? None
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? $2786.74
16. Why do you claim the City of Dubuque is responsible?
Mr. Thurston reported to me that he hit my van while driving the city trash truck.
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 20 day of July , 2002.
/s/ Monica Heri
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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: /~o~.lr_~--
2. Address: ~ ~:~ c~
·
3. Telephone Number: ~;>~
4. Date of Incident:
5. Time of Incident:
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. If a City employee was involved, give the
emplOyee's name.)~_~,~ -C~C~J~C~ {~ ~c~'. ~ L~ -~ ~ ~
8. What were weather conditions like? ~ ~c¢ m~C~ -~¢~ ~Ve~eA~
9. Give name and address of any witnesses:
10. Did police investigate? (if so, give names of officers.)
qc6 - fXr,,AC¢_ e-ex 3"q'A
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
12. Was any damage done to property? (If so, describe property and the extent of damagi~s.
Attabh estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you olaim, if any?~d~
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.)
15. What amount do you claim from the City of Dubuque?
16. Why do you claim the City of 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.) 7~
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 o~ ~ . day of
(Rev. 1/00 & 7/01)
~- I~-/ , 20 ~c~.
~_ (Signature)
(Print Name)
PHONE:
WILSON BROS. DODGE
90 JFK
DUBUQUE, IA 52002
(563)583-5781 FAX: (563)556-6928
FED TAX ID: 420779647
CD LOG NO 1917-1 DATE 07/17/02
SHOP:
ADDRESS:
CITY STATE:
ZIP:
WILSON BROS AUTO BODY
90 JFK
DUBUQUE, IA
52002-
INSP DATE:
CONTACT:
PHONE 2:
FAX:
07/17/02
JASON CHARLEY
(563)583-5781 EXT 230
(563)556-6928
OWNER:
ADDRESS:
CITY STATE:
ZIP:
SAWVELL, MONICA
2339 POPLAR
DUB, IA
52001-
HOME PHONE:
(563)582-5416
POINT OF IMPACT: 5
LIC#:
BODY COLOR:
CONDITION:
DARK GREEN
EXCL
STATE:
VIN:
MILEAGE:
ACCTNG CTL#:
2B4GP44GlXR136918
*=USER-ENTERED VALUE
EC=REPLACE ECONOMY
TE=PARTL REPL PRICE
I=REPAIR
TT=TWO-TONE
N=ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
E=REPLACE OEM
EU=REPLACE SALVAGE
ET=PARTL REPL LABOR
L=REFINISH
CG=CHIPGUARD
RI=R&I ASSEMBLY
RP=RELATED PRIOR
NG=REPLACE NAGS
EP=REPLACE PXN
IT=PARTIAL REPAIR
BR=BLEND REFINISH
SB=SUBLET
P=CHECK
UP=UNRELATED PRIOR
1999 DODGE CARAVAN GRAND SE 4DOOR PASSENGER VAN
CODE: N6624B/D OPTNS A/24HFRLMP
6CYL GASOLINE 3.3 FLEX
OPTIONS:
TWO-STAGE EXTERIOR SURFACES
SLIDING SIDE DOOR, LEFT
ANTI-LOCK BRAKE SYSTEM
AIR CONDITIONING
TWO-STAGE INTERIOR SURFACES
HEATED REMOTE CONTROL MIRRORS
TILT STEERING WHEEL
CRUISE CONTROL
OP GDE MC DESCRIPTION
E 0021 01 COVER, FRONT BUMPER
L 0021
BR 0083
RI 0086
E 0103
L 0103
E 0207
L 0207
E 0258
I 0217
O9
01
COVER, FRONT BUMPER
PANEL,HOOD
EMBLEM, HOOD PANEL
FENDER, FRONT
FENDER, FRONT
DOOR SHELL, FRONT
E
0231
LT
LT
LT
DOOR SHELL, FRONT LT
01 MLDG, FRONT DOOR SID LT
MIRROR, OUTER R/C LT
BUFF
HINGE, FRONT DOOR UP LT
MFG.PART NO. PRICE
5013485AA 392.00
REFINISH
BLEND REFINISH
R&I ASSEMBLY
4882291AA 143.00
REFINISH
4717429AB 650.00
REFINISH
PJ87SJ3 62.00
REPAIR
AJ% B%
HOURS R
2.21
2.54
1.64
0.11
3.51
2.54
4.01
3.84
0.31
0.3'1
4717209 26.10 0.2 1
PAGE 1
~999 DODGE, CARAVAN
CD~LbG NO 1917-1
GRAND SE 4DOOR PASSENGER VAN
L 0231
E 0233
L 0233
BR 0227
EC M07
N M14
P M60
E
HINGE, FRONT DOOR UP LT REFINISH
HINGE,FRONT DOOR LW LT 4717211 26.10
HINGE, FRONT DOOR LW LT REFINISH
DOOR SHELL,REAR LT BLEND REFINISH
PINSTRIPES-TAPE ECONOMY PART 15.00'
CORROSION PROTECTION ADDNL LABOR OPERA 8.00*
HAZARD. WSTE. REM. CHECK 4.00*
MISC CLIPS. ETC NEW PART 5.00*
0.24
0.21
0.2 4
1.54
0.3'1'
0.2*4*
'1'
19 ITEMS
MC MESSAGE (S)
01 CALL DEALER FOR EXACT PART NUMBER / PRICE
09 INCLUDES 0.6 HOURS MAJOR PANEL TWO-STAGE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
OTHER PARTS
PAINT MATERIAL
PARTS TOTAL
TAX ON PARTS @
6.000%
1,304.20
27.00
325.00
1,656.20
79.87
LABOR RATE REPLACE HRS REPAIR HRS
I-SHEET METAL 42.00 10.8 0.3
2-MECH/ELEC 51.00
3-FRAME 51.00
4-REFINISH 42.00 12.3 0.2
5-PAINT MATERIAL 26.00
LABOR TOTAL
TAX ON LABOR @ 6.000%
SUBLET REPAIRS
TOWING
STORAGE
466.20
525.00
991.20
59.47
GROSS TOTAL
2,786.74
NET TOTAL
2,786.74
ADP SHOPLINK UB303 ES CD LOG 1917-1 DATE 07/17/02 04:44:11PM R6.25
PXN:N/00/00/00/00 CUM:/// HOST LOG
(C) 1998 - 2002 ADP CLAIMS SOLUTIONS GROUP, INC.
CD 07/02
2.9 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FORMULA.
LIFETIME WARINTY ON PAINT ONE YEAR ON WORKMANSHIP NO WARINY ON RUSTWORK
PAGE 2
JOHNS BODY SHOP
3520 PERCIVAL STREET
HAZEL GREEN, WI 53811
PHONE: (608) 854-2341
FAX: (608} 854-2342
CE LOG NO 745-1 DATE 07/18/02
SHOP: JOHNS BODY SHOP
ADDRESS: PO BOX 85 3520 PERCIVAL ST.
CITY STATE: HAZEL GREEN, WI
ZIP: 53811-
INSP DATE:
CONTACT:
PHONE 1:
FAX:
07/18/02
MARK CURWEN
I608)854-2341
(608)854-2342
OWNER: SAWVELL, MONICA
ADDRESS: 2339 POPLAR
CITY STATE: DUB., IA
52001-
HOME PHONq'~:
(563)582-5416
POINT OF IMPACT: 4
LTC#:
BODy COLOR:
CONDITION:
STATE:
VIN:
MILEAGE:
ACCTNG CTL#:
254GP44G1XR136918
*=USER-ENTERED VALUE
EC~REPLACE ECONOMY
TE~PARTL REPL PRICE
I~REPAIR
TT~TWO-TONE
N~ADDITIONAL LABOR
AA=APPEAR ALLOWANCE
E-REPLACE OEM
EU=REPLACE SALVAGE
ET=PARTL REPL LABOR
L=REFINiSH
CG~CHIPGUARD
RI=R&i ASSEMBLY
RP=RELATED PRIOR
NG=R~PLACE NAGS
EP=REPLACE PXN
IT=PARTIAL REPAIR
PR-BLEND REFINISH
SE'SUBLET
P=CHECK
UP-UNRELATED PRIOR
1999 DODGE CARAVAN GP~ND SE 4DOOR PASSENGER VAN
CODE: N6624B/D OPTNS A/24HFRLMP
6CYL GASOLINE 3.3 FLEX
OPTIONS:
TWO-STAGE - EXTERIOR SURFACES
SLIDING SIDE DOOR,LEFT
ANTI-LOCK B~KE SYSTEM
AIR CONDITIONING
TWO-STAGE - INTERIOR SURFACES
HEATED REMOTE CONTROL MIRRORS
TILT STEERING WHEEL
CRUISE CONTROL
OP GDE
E 0013
L 0013
L ~083
E 0086
E 0103
L 0103
E 020'7
L 0207
E 0258
I 0217
L 0217
E 023!
MC DESCRIPTION
COVER, FRONT BUMPER
09 CO%~R, FRONT BUMPER
PANEL, HOOD
01 EMBLEM, MOOD PANEL
FENDER, FRONT
FENDER, FRONT
DOOR SHELL, FRONT
01
LT
LT
LT
DOOR SHELL, FRONT LT
MLDG, FRONT DOOR SID LT
MIRROR, OUTER R/C LT
MIRROR, OUTER R/C LT
HINGE,FRONT DOOR UP LT
MFG.PART NO. PRICE
5013042AA 347.00
REFINISH
REFINISH
KS76SHH !6.25
4882291AA 143.00
REFINISH
4717429AB 650.00
-REFINISH
PJ87SJ3 62.00
REPAIR
REFINISH
~?17209
AJ% 5%
HOURS R
2.2i
3.54
3.1 4
0.1 1
3,51
2,5~
4.01
3.84
0.31
0,3'1
0.4 4
0.21
PAGE i
1995 DODGE CARAVAN
*CD'LOG NO 745-I
GRAND SE 4DOOR PASSENGER
L 0231
E 0233
L 0233
BR 0227
EC M07
I M!4
L
HINGE,FRONT DOOR UP LT REFINISH
HINGE, FRONT DOOR LW LT 4717211
HiNGE, FRONT DOOR LW LT REFINISH
DOOR SH~LL~HEAR LT BLEND REFINISH
PINSTRIPES-TAP~ ECONOMY PART
CORROSION PROTECTION SUBLET REPAIR
COVER CAR EXTERIOR REFINZSH
26.10
15.00'
10.00'
7.00'
0.2 4
0.2 1
0.24
1.54
1
0.3*4
19 ITEMS
MC MESSAGE(S)
01 CA~L DEALER FOR EXACT PART NUMBER / PRICE
09 INCLUDES 0.6 HOURS MAJOR PANEL TWO-STAgE ALLOWANCE
FINAL CALCULATIONS & ENTRIES
GROSS PARTS
OTEER PARTS
PAINT MATERIAL
PARTS TOTAL
TAX ON PARTS & MATERIAL
5.500%
1,270.45
22.00
387.50
1,679.95
92.40
tJ%BOR PATE REPLACE HRS REPAIR HRS
1-SHEET METAL 40.00 10.5 0.3 432.00
2-MECH/ELEC 40.00
3-FRAME 40.00
4-REFINISH 40.00 15.2 0.3 620.00
5-PAINT MATERIAL 25.00
LABOR TOTAL 1,052.00
TAX ON LA2BOR @ 5.500% 57.86
SUBLET REPAIRS 10.00
T~uX ON SUBLET ~ 5.500% 0.55
TOWING
STORAGE
GROSS TOTAL
2.892.76
NET TOTAL
ADP SHOPLINK UC253 ES CD LOG 745-1 DATE 07/18/02 09:28:23AM R6'2
PXN:N/00/00/00/00 CUM:/// HOST LOG
COPYRIGHT 2000, AUTOMATIC DATA PROCESSING, INC.
2,892.76
CD 05/02
3.1 HRS WERE ADDED TO THIS EST. BASED ON ADP TWO-STAGE REFINISH FO~ULA.
PAID IN FULL
~MOUNT PAIU
CHECK $
CASH
PAGE 2