Claim Griebel, RebeccaCLAIM 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.
OBce 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 ~gUR. CLAIM WILL~ OR WILL~NOT~ BE PAID..
1. Name of Claimant= I'x~i~0d~,~f~ ~Ft
2. Address: ~ ~]~(. ~ .
3. Telephone Number: ~ ~ ~ 5 ~ ?
5. Timeoflncident: ~ ~(~ ~ .
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a City~m~oy~e was~voJyed, give the
employee's name.) ~ ~ ~ ~[[~
' ' - ~ ......... 0 "' - 0 ' , '
8. Whet were weather conditions like? ~
~. ~i,e ,~m. ana a~a,es, of any wi~.esses:
~0. o)~ ~o,ce inws~i~a~e~ Of ~o, gi~ n~me~ of o.ic~r~.)
11. Was anyone iniured? (If so, give names, addresses, and extent of injuries).
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 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. Whydo you claim the City of Dubuque is responsible?
17. Have you made any ~laim against anyone el~e far damagas as a result of this incident?
(If yes, give name and address.) .~ ~A
,/
18. If the answer to Question 17 .is yes, have you received any payment from that source,
and if so, in what amount? , ~/A
Dated at Dubuque, Iowa this
day of
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
Operations and Maintenance Department
925 Kerper Boulevard
Dubuque, Iowa 52001-2338
(563) 589-4250 office
(563) 5894252 fax
(563) 5894193 TDD
ops&maint~cityofdul:mque.org
Dear SidMs:
The City of Dubuque Operations & Maintenance Department
acknowledges that we have damaged your property, building and/or
vehicle. Since the employee's supervisor has determined that the
estimated cost to repair the damage does not exceed $1,000.00, the
Police Department was not required to assist with paperwork,
investigation, etc..
Please contact the City Clerk at 589-4120 to obtain a damage claim
form.
We apologize for the damage we have caused and the
inconveniences that have resulted for you.
Sincerely,
Service People htteo~ity Responsibili~ Innovation Teamwork
OWR~ STATES CAR ~.S PUS~-~ AHEAD 4 FEET
/? ON IF CAR WILL H~VE TRANS PROLa~.~.MS ???
Date: 9/27102 03:20 PM
Estimate ID: 7t 93
Estimate Version: 0
Preliminary
Profile ID:. CUSTOMIZED
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(563) 583-912t
Fax: (563) 556.4482
Tax ID: 42-0400210
Damage Assessed By: JOHN KLOTZ JR.
Oeducfl'ble: UNKNOWN
Owner BECKY GRIEBEL
Address: 1850 CANNON ST DUBUQUE, IA 52003
Telephone: Home Phone: (563) 588-1051
Mitchell Service: 918494
Description: 2000 Cbovmle~ Prizm
Body Style: 4D Sed Drive Train: 1.8L Inj 4 Cyl 3A
YIN: 1Yt SK5286YZ412946
Mileage: 12,326
Color: MAROON
Options: AIR CONDITIONING, POWER STEERING, ELECTRIC DEFOGGER, AM-FM STEREO
AUTOMATIC TRANSMISSION
Line Entry Labor Line item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Units
801245 MCH ALIGN
801360 BDY REMOVE/REPLACE
801392 BDY REMOVE/REPLACE
AUTO REF REFINISH
AUTO REF ADD'L OPR
AUTO ADD'L COST
AUTO ADD'L COST
FOUR WHEEL
L COMBINATION LAMP ASSEMBLY
REAR BUMPER COVER
REAR BUMPER COVER
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
GM PART
GM PART
tA
95.80 0.5 #
392.03 1.5
C 2.4
1.0
88A0'
3.06 *
* - Judgement Item
~ - Labor Note Applies
C - Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 9/27102 15:20:t5 7t93
UltmMate is a Trademark of Mitchell International
Mitchell Data Vemion: SEP_02_A Copyright (C) 1994 - 2002 Mitchell International
UltraMate Version: 4.8.0t t All RIghts Reserved
Page
of 2
Date: 9/27102 03:20 PM
Estimate ID: 7t93
EstJmete Version: 0
Preliminary
Profile I~. CUSTOMIZED
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals
Body 2.0 45.00 0.00 0.00 90.00 T
Refinish 3.4 45.00 0.00 0.00 153.00 T
Mechan~na[ 1.4 5?-00 0.00 0.00 72.80 T
Taxable Labor 3t5.80
Labor Tax ~ 6.000 % 18.95
Labor Summary 6.8
IlL Additional Costs
Non-Taxable
Total Additional Costs
334.75
Amount
91.46
9t,46
il. Part Replacement Summary
Taxable Parts
Sales 'lax ~
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
I. Total Labor:
II. Total Replacement Parts:
IlL Total Additional Costs:
Gross Total:
0.000%
Amount
517.10
Amount
0.00
334.75
5'17.10
9'1.46
943.31
IV. Total Adjustments:
Net Total:
0.00
943.31
This is a preliminary estimate.
Additional chartres to the estimate may be required for the actual repair.
PARTS PRICES ARE SUBJECT TO CHANGE
WARNING: Accidental air bag deployment is possible. Personal injury may resulL Avoid area naar staering wheel
and inal~enent panel even flair bags have deployed. Duai-stage air bag modules may bo present that could
contain an undeploynd stage. When dlspoaing of a deployed dual-etage air bag, always treat it as a "live" module.
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM information.
ESTIMATE RECALL NUMBER: 9127102'15:20:15 7193
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: SEP_02_A Copyright (C) 1994- 2002 Mitchell International
UltrsMete Version: 4.8.011 All Rights Reserved
Page 2 of
FED ID #42-0813744
D~; ~,'~0.~0o~ 01:48 PM
Prolite ID: Mftchell
RICHARDSON MOTORS
1475 J.F.K. ROAD DUBUQUE, IA
Fax: (6S3) 582-4129
Damage Assessed By: AL COGHLAN
Deductrble: UNKNOWN
Owner BECKY GRIEBEL
Telephone: Home Phone: (Sb'~) S85-105t
Line Entry Labor Line Ib~n Part Type/
Iter~t Nurr~ber ~ O~era~'j~q __ ~H~ion P~ N~r
1 ~316 MCH ALIGN FOUR WH~L -M
2 8013e0 8DY REMOV~P~CE
3 801~ BOY ~MOV~
· ~1'0 REF ~INISH
5 A~O ~F A~'L O~
6 AUTO ~D% C~T
L COMBINATION LAMP ASSEMBLy
REAR BUMPER COVER
RF_AR BUMPER COVER
CLEAR COAT
PAINT/MATERIALS
IIP,2LRRDOu~ WASTE DLSPOSAL
94867201 GM PART
* - Judgement item
# - Labor Note Applies
C - Included in Clear Coat Calc
Dollar Labor
Amount Units
1~4
96.80 0.5 #
392.03
C 2.4
Labor Suble~
L Labor Subtotals Units Rate Amount Amount To~ls
tBo~y 2.0 45.00 0.00 O.OO 85.00
II. Part Replacement Summary
Taxable Parts
Sales Ta~ ~
Total Replacement Pa~ts Amount
UltraMate is a Trademark of Mitchell Intematior~al
Copyright lC) 1994. 2002 Mitchell International
Amount
ll.o00% 29.2.7
Page I of 2
ill. Additional Co, ts
Taxable
~:~lc~ Tax
Non-Taxable Co,~s
Date: 9/30/2M2 0'L'4& PM
Estimate Version: 0
Preliminary
Profile ~: Mitc~
· Ampunt IV. Adju~,nent$
$.~0
e.~ CLrs~O~r Res~nsibi~¥
96.20
101.;G
Gross
IV. Tol~l Adju~
Net
This is a Preliminary estima~
Addit/ona changes t~the estimate may be re~uire~ a~b~.
G17.10
101.56
95't.41
0.~
WAP,~G: AcCidental ab' bag d~oyme~t is ~=*ble~ PersOnal ~ju~ my =~ Avoid a~ ~r ~ ~1
~d ~m~nt ~nel ev~ i~ air ~gs ba~ d~oy~
- . ~al~ge air ~g ~ul~ ~y ~ p~ ~at ~uld
~ approp~ M~H~ ~R ~O S~V~ & ~ M~U~ or OEM i~tis~
EaT]MATE RECALL NUMBER: 9/30t2002 13.'43:26 713~
Ul~'aMate is a Traden~ of Mitchell Jntenmttonal
Mitchell Data Version: SEP 02 A Copyright (C) 1994.2002 Mitchell bltemaflonal
UlttaMa~e Version: 4.g.o~ 1 -- All Rk3~ Reserved
Page 2 of 2