Claim by Scott D. Hoss
CLAIM 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 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.
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1. Name of Claimant: ~ Cy t I 1 J ;~
2. Address: /~~~ ~c,,-'~-~ ~a~ccr~/~ ~~~~ .iJ~/~--~~
3. Telephone Number ~"~ G~ 3 - ~~~~~~~ ~ ~ ~ -~U ~
4. Date of Incident: / - ~ - ~ 9
5. Time of Incident: /~ ~ ~~ ~f~" x'1'1
6/~Location of Incident (Bes(p~ecific): /,
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
t e employee's name.)
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8. What were weather conditions like? n `n
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9. Give name and address of any witnesses: _ ~a - ~~ ~ ~~
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10. Did police investigate? (If so, give names of officers.) ~
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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?
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 amount do you claim from the City of Dubuque?
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16. Why do you claim the City of Dubuque is responsible?
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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.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
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Dated day of :~ ~ , 20 n 9. __
(Signature)
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(Print Name)
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.)
Date: 1/ 8/2009 02:04 PM
Estimate ID: 225
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Hanley Auto Body Inc.
1030 Century Circle, Dubuque, IA 52002
(563) 583-7220
Fax: (563) 583-8355
Damage Assessed By: Robert Hanley
Deductible: UNKNOWN
Owner: Scott Hos
Address: 12252 North Cascade Rd., Dubuque, IA 52003
Telephone: Home Phone: (563) 5564018
Mitchell Service: 815495
Description: 2006 Chevrolet Pickup Silverado K2500 HD LS
Body Style: 4D PkupCrw 8' Bed 167" WB Drive Train: 6.OL Inj 8 Cyl 4WD
VIN: 1GCHK23U 1BF 184703
Options: 4WD OR AWD, AIR CONDITIONING, POWER DOOR LOCKS, CRUISE CONTROL
AUTOMATIC TRANSMISSION
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
1 501427 REF REFINISH L BED OUTER SIDE PANEL
2 504148 BDY REPAIR L PICKUP BED SIDE PANEL ASSY Existing
3 AUTO REF ADD'L OPR CLEAR COAT
4 AUTO ADD'L COST PAINT/MATERIALS
5 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
"` -Judgment Item
# -Labor Note Applies
C -Included in Clear Coat Calc
Estimate Totals
Dollar Labor
Amount Units
C 2.0'
1.0' #
1.3
99.00
5.00
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Surrrr~ary Amount
Body 1.0 48.00 0.00 0.00 48.00 T
Refinish 3.3 48.00 0.00 0.00 158.40 T Total Replacement Parts Amount 0.00
Taxable Labor 206.40
Labor Tax ~ 7.000 % 14.45
Labor Summary 4.3 220.85
ESTIMATE RECALL NUMBER: 01/08/2009 14:04:22 225
Mitchell Data Version: NOV_08_A UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2008 Mitchell International Page 1 of 2
UltraMate Version: 6.7.017 All Rights Reserved
Date: 1/ 8/2009 02:04 PM
Estimate ID: 225
Estimate Version: 0
Preliminary
Profile ID: Mkchell
111. Addkional Costs
Non-Taxable Costs
Total Addkional Costs
Amount IV. Adjustments
104.00 Customer Responsibil"rtY
104.00
Amount
0.00
I. Total Labor:
11. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual reuair.
ESTIMATE RECALL NUMBER: 01/08/2009 14:04:22 225
Mkchell Data Version: NOV_08_A UltraMate is a Trademark of Mkchell International
Copyright (C) 1994 - 2008 Mkchell International
UkraMate Version: 6.7.017 All Rights Reserved
220.85
0.00
104.00
324.85
0.00
324.85
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