Claim by Gordon Dailey 2 9 09/~, e ;
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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 13t" 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
repork 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/~t'o you as to whether~your claimw~ill;o~r will nJot be paid.
1. Name of Claimant: ('°t~~`".~~~-% `1~ , L~ . / /,~~ / t
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2. Address: ~`:~ ~~%° ~ ..~ .~?a~ :s~-:b'~f ~a7~. ~ ~'~ ~~~. -~"_ ~ 1-~-~--~,
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3. Telephone Number: _ ~ ~ .~ ".~ ld ~~ d
4. Date of Incident: ~,~ ~ ~~~~
5. Time of Incident: a%~° a"~ ~~~~~ ~ ~~-~ K ~=` ~~(
6. Location of Incident (Be specific): d'~l~,r~.'~.~%~ ~~~- ~~~ ~-~''r~ ~~"'~~
7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your
claim. If a Cit employee was invoi~ved, give the employee's name.)
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8. What were weather condit~ s like? ~f ~~t-t- ~ ;~~~ _ cs_.~~
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9. Give name and address of any witnesses: ~du~ ~ ~ ~ ~1 ~~ ~1~~ [~ ~~~ ~'
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10. Did police investigate? (If so, give names of officers.)
11. ~as 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 e~tir~ates'of
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damages or describe basis for ascertaining extent of damage.) r
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13. What other damages do you claim, if any? / 1 1 ~ 1 ~'C~`~ ~ ~ ~ /. ~, %~`
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14. Have you been compensated for any part or all of your claim by any insurance~ompany? (If so, give ~aan
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 esponsible? ~~~ ,,,''Z~`~;=-
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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.)
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 this day of +~~~~~°~~-~_ , 20.~
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(Signature)
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(Print Name)
01/28/2009 at 02:48 PM
24443
ABRA - DUBUQUE
Federal ID #:420782245
DBA: ANDERSON-WEBER INC
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563)556-0696 Fax: (563)556-1899
PRELIMINARY ESTIMATE
Written By: RICK KELLY
Adjuster:
Insured: GORDON DAILEY
Owner: GORDON DAILEY
Address: 1860 AUDOBON ST
DUBUQUE, IA-52001
Evening: (563)543-3083
Inspect ABRA - DUBUQUE
Location: 3400 CENTER GROVE DR
DUBUQUE, IA 52003
Insurance PUBLIC ENTITY
C~.«,b,any :
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Job Number:
12. Front
Business: (563)556-0696
Days to Repair
2007 HOND ELEMENT 4X4 EX 4-2.4L-FI 4D UTV GREEN Int:
VIN: 5J6YH28747L015404 Lic: Prod Date: Odometer:
Air Conditioning Rear Defogger Tilt Wheel
Cruise Control Intermittent Wipers Keyless Entry
Rear Window Wiper Steering Wheel Contro ls Dual Mirrors
Privacy Glass Console/Storage Overhead Console
Clear Coat Paint Power Steering Power Brakes
Power Windows Power Locks Power Mirrors
AM Radio FM Radio Stereo
CD Player Anti-Lock Brakes (4) Driver Air Bag
Passenger Air Bag Head/Curtain Air Bags Front Side Impact Air Bag
4 Wheel Disc Brakes Traction Control Cloth Seats
Bucket Seats Power Trunk/Tailgate Automatic Transmission
4 Wheel Drive Overdrive
-----
---- Aluminum/Alloy Wheels
---------------------------
--------------------
NO. OP.
- -----------------------
DESCRIPTION
---------------------------- QTY
---- EXT. PRICE LABOR PAINT
---------------------------
-------------------
1 FRONT BUMPER
2 Repl Bumper cover EX dark gray 1 191.11 1.8 3.2
3 Add for Clear Coat 0 0.00 0.0 1.3
4* Rpr Rei nf beam 0 0.00 1.0 0.0
5 FENDER
6 Blnd RT Fender 0 0.00 0.0 0.8
7 Blnd LT Fender 0 0.00 0.0 0.8
8 R&I RT Cladding EX 0 0.00 0.5 0.0
9 R&I LT Cladding EX 0 0.00 0.5 0.0
10# Blnd LT CLADDING 0 0.00 0.0 0.4
1
01/28/2009 at 02:48 PM
24443
Job Number:
PRELIMI Y ESTII~lATE
2007 HOND ELEMENT 4X4 EX 4-2.4L-FI 4D UTV GREEN Int:
---------
NO. -------
OP. -------------------------------
DESCRIPTION ---------------
QTY EXT. PRICE
--------------- ---------
LABOR
--------- --------
PAINT
--------
---------
11# -------
Blnd -------------------------------
RT CLADDING 0 0.00 0.0 0.4
12 FRONT LAMPS
13 R&I RT Side marker lamp 0 0.00 Incl. 0.0
14 R&I LT Side marker lamp 0 0.00 Incl. 0.0
15# Subl hazardous waste 1 4.00 T 0.0 0.0
16# Subl bag car 1 10.00
------- T
-- 0.0
--------- 0.0
--------
--------- ------- -------------------------------
Subtotals =_> --- ---
205.11 3.8 6.9
Parts 191.11
Body Labor 3.8 hrs @ $ 52.00/hr .197.60
Paint Labor 6.9 hrs @ $ 52.00/hr 358.80
Paint Supplies 6.9 hrs @ $ 33.00/hr 227.70
Sublet/Misc.
--
--
--------- 14.00
--------
-------------------
SUBTOTAL ---- -------- $ 989.21
Sales Tax $ 761.51 @ 7.0000 53.31
GRAND TOTAL $ 1042.52
ADJUSTMENTS:
Deductible 0.00
----------------------------------------------------
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 1042.52
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
2
01/28/2009 at 02:48 PM
24443
Job Number:
PRELIMIN~iRSC ESTIMATE
2007 HOND ELEMENT 4X4 EX 4-2.4L-FI 4D UTV GREEN Int:
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived
from the Guide ARG4450, CCC Data Date 01/02/2009, and the parts selected are OEM-parts
manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at
OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts
that may be provided by or through alternate sources other than the OEM vehicle dealerships.
OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT
OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle
dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor
information provided by MOTOR may have been modified or may have come from an alternate data
source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. .Non-Original
Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts
which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy
Parts, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described
as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass
Specifications. Labor operation times listed on the line with the NAGS information are MOTOR
suggested labor operation times. NAGS labor operation times are not included. Pound sign (#)
items indicate manual entries. Some 2009 vehicles contain minor changes from the. previous year.
For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and
parts data from the previous year may be used. The Pathways estimator has a complete list of
applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
CCC Pathways - A product of CCC Information Services Inc.
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