Claim by Suellen Flynn 2 10 09I I T I1°Y U U ~, I
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. 13t" 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.
4. Date of Incident: ~ : ~, ~ --- v 9
5. Time of Incident: ~7 : ~ ~ ~ . nn ~ >
6. Location of Incident (Be specific): 7ti e _ r~ ~ ~a ~ ,~ ~ c~ ~ ~c.-~ d c~ ~ ?~~,~~.
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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.) ((~~
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8. What were weather conditions like? C~ ~' c~ r
9. Give name and address of any witnesses:
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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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.)
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13. What other damages do you claim, if any? F-~~ r, ~
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 l!responsiblpe? ) pp~
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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?
Dated at Dubuque, Iowa this ~fh day of ~-~ ~, r~i c, r~ __ _ ®, 20 d 9 .
f n/~ Q~ ~~~, ~ n (Signature)
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~)~i e_~ ~-f~~ ~1 ~~, (Print Name)
(Rev. 1 /00 & 7/01)
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Date: 2/ 9/2009 12:06 PM
Estimate ID: 460
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Damage Assessed By: Robert Hanley
Deductible: UNKNOWN
Owner: Denis Flynn
Address: 4751 Glen Oak, Dubuque, IA 52001
Telephone: Home Phone: (563} 556-5143
Description: 1995 Chevrolet Corsica
Body Style: 4D Sed
VIN: 1GiLD55 M4SY163922
Mileage: 75,518
Color: Red
~ ~t '~.
1030 Century Circle, Dubuque, IA 52002
(563) 583-7220
Fax: (563} 583-8355
C
Mitchell Service: 911482
Vehicle Production Date: 11/94
Drive Train: 3.1L Inj 6 Cyl A
License: 520 MOJ IA
Line Entry Labor Line Item
Item Number Type Operation Description
1 123960 BDY REPAIR L FRT DOOR SHELL
2 AUTO REF REFINISH L FRT DOOR OUTSIDE
3 100448 REF REFINISH L FRT DOOR MIRROR
4 124790 BDY REMOVE/REPLACE L FRT DOOR REAR VIEW MIRROR
5 AUTO REF ADD'L OPR CLEAR COAT
6 AUTO ADD'L COST PAINT/MATERIALS
7 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
* -Judgment Item
# -Labor Note Applies
C -Included in Clear Coat Calc
StltYtat@ TOt1IS
Part Type!
Part Number
Existing
** QUAL REPL PART
Add?
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary
Body 3.6 48.00 0.00 OAO 172.80 T Taxable Parts
Refinish 3.8 48.00 0.00 0.00 182.40 T Sales Tax @
Taxable Labor 355.20 Total Replacement Parts Amount
Labor Tax @ 7.000 % 24.86
Labor Summary 7.4 380.06
ESTIMATE RECALL NUMBER: 02!0912009 12:05:52 460
Mitchell Data Version: JAN_09_A UltraMate is a Trademark of Mitchell International
Copyright (C} 1994 - 2009 Mitchell International
UltraMate Version: 6.7.019 All Rights Reserved
G
Dollar Labor
Amount Units
3.0*
C 2.3
C 0.5
97.00 ~ 0.6 #
1.0
114.00 *
5.00
7.000%
Amount
97.00
6.79
103.79
Page 1 of 2
Date: 2/ 9/2009 12:06 PM
Estimate ID: 460
Estimate Version: 0
Preliminary
Profile ID: Mitchell
III. Additional Costs Amount IV. Adjustments Amount
Non-Taxable Gosts 119.00 Customer Responsibility 0.00
Total Additional Costs 119.00
1. Total Labor: 380.06
II. Total Replacement Parts: 103.79
III. Total Additional Costs: 119.00
Gross Total: 602.85
IV. Total Adjustments: 0.00
Net Total: 602.85
This is a areliminarv estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 02/09/2009 12:05:52 460
Mitchell Data Version: JAN_09_A UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 2 of 2
UltraMate Version: 6.1.019 All Rights Reserved