Claim, Foley, Geraldine A.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 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: Geraldine A. Foley
2. Address: 12624 Westmont Heights Peosta, IA 52068
3. Telephone Number: 563 582 2185
4. Date of Incident: 9-17-02
5. Time of Incident: 0837
6. Location of Incident (Be specific): At the interseciton of Old Higway Road and Seippel Rd.
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.)
I was traveling east on Old Highway Rd. turning Left to SEippel Road when the Dub. City worker in Dub. City Truck, Ronald Henry, pulld out from stopping at the Seippel Stop sign and struck the L rear side of my van.
8. What were weather conditions like? Sunny & warm
9. Give name and address of any witnesses:
Another passenger in the City of Dub vehicle Chris Kloft.
10. Did police investigate? (If so, give names of officers.)
Yes Mark Stone
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
none injured
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.)
Damage to the Left rear of my van
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? Total repair of the van, see estimate
16. Why do you claim the City of Dubuque is responsible?
The worker who hit me was working for the City of Dubuque in a Dub. City vehicle.
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 25th day of September, 2002.
/s/ Gerald A. Foley
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 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:
2. Address:
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.) ,
8. What were weather conditions like? ~
~J
Give name and address of any witnesses:
9.
10. Did police investigate? (If so, give names of officers.)
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 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.)
NO
15. What amount do you claim from the City of Dubuque?
J
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.)
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 ~ 5''~ day of
[-~ ~ ~ ~ (Signatur~
~: ~ (Print Nam~
(Rev. 1/00 & 7/01)
Date: 9/24/02 01:59 PM
Estimate ID: 3759
F_.s~mate Version: 0
Pre#minary
Profi~ ID: Mitchell
Dan Kruse Pontiac, Nissan, BlqW
600 Century Drive Dubuque, IA 52002
(562) S~-754S
Fax: (sb'3) s88~4
Deductible: UNKNOWN
Insured: GERRI FOLEY
Address: 12624 WEST MOUNT HEIGHTS PEOSTA, IA 62068
Telephone: Home Phone: (563) 582-2185
Mitchell Service: 917493
Desc~ption: 1997 Pontiac TransSport SE
BodyStyl~ VanExt120'WB Drive Train: 3ALInj6Cyl2WD
VIN: 1GMDX06ESVD262431
Options: AIR CONDITIONING, POtN~R STEERING, POWER BRAKES, POWER WINDOWS, POWER DOOR LOCKS
TILT STEERING WHEEL, CRUISE CONTROL, AM-FM STEREO, AUTOMATIC TRANSMISSION
Item Number Type Operation Onscdption Part Number
Dollar Labor
.~ount Units
1
2
3
4
7
8
9
702055 BDY REPAIR L OTR QUARTER BODY SIDE PANEL Existing
AUTO REF REFINISH L VAN SIDE PANEL OUTSIDE
701484 BDY REMOVE/REPLACE L REAR COMBINATION LAMP ASSEMBLY 10432599
701533 BDY REMOVE/REPLACE REAR BUMPERCOVER 10410470
AUTO REF REFINISH REAR BUMPER COVER
AUTO REF ADD1. OPR CLEAR COAT
623095 BDY ADD'I- OPR RESTORE CORROSION PROTECTION
AUTO ADD'L COST PAINT/MATERIALS
AUTO ADD~. COST HAZARDOUS WASTE DISPOSAL
* - Judgement Item
C - Included in Clear Coat Calc
GM PART
GM PART
12.0'
C 3.O
58.50 0.3
621.O3 1.3
C 2.3
1.7'
5.O0' 0~
175.00 *
3.50 *
Remarks
WILL TRy TO STR. LEFT QUARTER MAY HAVE TO BE REPLACED
ESTIMATE RECALL NUMBER: 9/24/02 13:47~5 3759
UitraMate is a Trade,hark of Mitchell International
Mitchell Data Version: SEP_O2_A CopyrigM (C) 1994 - 2003 Mitchell International
UitraMate Version: 43.011 AIl RIghts Reserved
Page I of 2
III.
Date: 9/24~2 01:59 PM
Estimate ID: 3759
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Addl
Labor Sublet
Labor Subtotals Units Rate Amount Amount Totals II. Pa~t Replacement Sunmmry
Body 13.9 45.59 5.00 0.59 630.50 T Taxable Parts
Refinish 7.0 45-90 0.50 0.59 310.00 T Sales Tax ~
Taxable Labor 945.50
Labor Tax ~ 6.590 % 96,73
20.9 1,592.23
Total Replacement Parts Amount
9.5O0%
Non-Taxable Costs
Total Additional Costs
178.50
170.50
IV. Adjustments
Customer Responsibility
I. Total
II. Total Replacement Parts:
IlL Total Additional
Gross Total:
IV. Total Adjustments:
Net Total:
This is a preliminary estinmte.
Additional chanqes to the estimate may be required for the actual repair.
T~£S DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER AN~ ADDIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER
TB~ WORK HAS BEEN OPENED UP THE INS,¥r/LL BE NOTIFIED.
WE FE~TU~ A THREE YEAR WORKMANSHIP LIMITED WARRANTY- SEE OUR WRI~'T~t~
WAI~/~TX FOR COMPLETE DETAILS. (EFECTIVE 10-01-01)
359.33
23A2
413.75
Amount
0.59
1,002.23
413.75
178-50
1,59448
0.59
WARNING: Accidental air bag deployment is possible. Personal injury may result. Avoid area near steering wheel
and in~'ument panel even if air bags have deployed. Dual-stage air bag modules may be present that could
contain on undeployed stage. When dis~postm~ of a deployed duel-stage air bag, always treat it as a 'live" module.
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM information.
ESTIMATE RECALL NUMBER: 9/24/02 13:47:55 3759
U#raMnte is a Trademark of Mitchell Intemstional
Mitchell Data Version: SEP_O2_A Copyrig~t (C) 1994 - 2002 Mitc#eit International
UitraMate Version: 4.5.011 All RigMs Resers~d
Page 2 of 2
Date: 09/24/2002 01:28 PM
Estimate ID: 6797
EsfimMe Version: 0
Preliminary
Profile ID: Mitchell
MIKE FINNIN FORD, INC.
3600 DODGE STREET DUBUQUE, IA52003
(563)566-10t0
Fax: (563)6904086
Tax ID: 42-1074463
Damage Assessed By: PAT GRUTZ
D~luctible: UNKNOWN
Insured: JERRI FOLLEY
Address: 12624 WEST MOUNT HEIGHTS PEOSTA, IA 62068
Telephone: Home Phone: (663) 682-2185
Mitchell Service: 917493
Description: 1997 Pontiac TransSport SE
Body Style: VanExt 120" 'eVB Drive Train: 3.4L Inj 6 Cyl 2WD
VIN: 1GMDX06ESVD203431
Options: AIR CONDITIONING, POWER STEERING, POWER BRAKES, POWER WINDOWS, POWER DOOR LOCKS
TILT STEERING WHEEL, CRUISE CONTROL, AM-FM STEREO, AUTOMATIC TRANSMISSION
Line Entry Labor Line Item Part Type/
Item Number Type OperaUon Descripiton Part Number
Dollar Labo~
Amount Units
I 702055 BDY REPAIR
2 AUTO REF REFINISH
3 702078 BDY REMOVE/INSTALL
4 702091 BOY REMOVE/INSTALL
5 702678 GLS REMOVE/INSTALL
6 702687 GLS REMOVE/INSTALL
7 701484 BDY REMOVE/REPLACE
8 701533 BOY REMOVE/REPLACE
9 AUTO REF REFINISH
10 AUTO REF ADD'L OPR
11 933018 REF ADD'L OPR
12 AUTO ADD'L COST
13 AUTO ADD'L COST
L OTR QUARTER BODY SIDE PANEL Existing
L VAN SlOE PANEL OUTSIDE
L FRT QUARTER MOULDING Existing
L QUARTER W/OPENING MLDG Existing
L FRT QTR GLASS MOVEABLE Existing
L REAR QTR GLASS MOVEABLE Existing
L REAR COMBINATION LAMP ASSEMBLY 10432599
REAR BUMPER COVER 18410470
REAR BUMPER COVER
CLEAR COAT
MASK FOR OVERSPRAY
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
GM PART
GM PART
12.0'
C 3.0
0.4*
0.3*
1.0'
1.3'
58.50 0.3
331.83 1.3
C 2.3
1.7
10.00' 0.2*
196.00 *
3.60 *
* - Judgement item
C - Included in Clear Coat Calc
Remarks
CITY OF DUBUQUE IS THE CONTACT PEOPLE
ESTIMATE RECALL NUMBER: 09/24/2002 13:13:16 6797
UltreMate is a Trademark of Mitchell International
Mitchell DMa Vemion: SEP_02_A Copyright (C) 1994 - 2002 Mitchell International
UltraMate Version: 4.8.011 All RIghts Reserved
Page 1 of 2
Date: 09124/2002 01:28 PM
Estimate ID: 6797
E~ Version: 0
Preliminary
Profile ID: Mitchell
L Labor Subtotals Units Rate
Body 1~3 45.00
Refinish 7~ 45.00
Glass 2~ 45~0
Add'l
Labor Sublet
Amount Amount Totals
0.00 0.00 643.50 T
t9.00 0.80 334.00 T
0.00 0.00 103.60 T
Taxable Labor 1,081.00
Labor Tax ~ 6.000 % 64.86
LaborSummary 23~
III. Additional Costs
Non-Taxable Costs
Total Additional Costs
1,145.86
9. Par~ Replacement Summary
Taxable Parts
Sales Tax
Total Replacement Parts Amount
Amount IV. Adjustments
199.50 Customer Responsibility
199.90
6.960%
Amount
390.33
23.42
413.75
Amount
0.00
L Total Labor:
II. Total Replacement Parts:
IlL Total Additional Costs:
Gross Total:
1,145.86
413~$
199.50
1,759.11
IV. Total Adjuslmente:
Net Total:
0.00
1,759.11
This is a preliminary estimate.
Additional chan,qes to the estimate may be required for the actual repair.
WARNING: Accidental air bag deployment is possible. Personal injury may result. Avoid area near steering wheel
and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could
contain an undeployed stage. When disposing of a deployed dual-stage air bag, always treat it as a 'live" module.
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM informaUon.
ESTIMATE RECALL NUMBER: 09~24/2002 13:13:16 6797
UltraMate is a Trademark of Mitehsil Ibternstional
Mitchell Data Version: SEP_02_A Copyright (C) 19~4 - 2002 Mitchell Intemstional
UltrsMate Version: 4.8.011 NI Rights Reserved
Page 2 of 2