Claim by Jennifer Ney 2 11 09F
v
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.
1. Name of Claimant:
2. Address:
3. Telephone Number
4. Date of Incident:
5. Time of Incident:
1 F >>
pI ~
i
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6. Loca ' _n of ident specifi
~/ - ~ ,
7. Describe the 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 vvea. ,e n.ditions like?
9. Give name and address of any. witnesses:
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, dive name and address of insurance company and
amount paid.)
1
15. What amount do you claim from the City of Dubuque?
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.)
T
18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in whgt amount?
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MARS MAIL REPORTS TO: ,~ (
t .. '®~ ~~~~~ ~f,°~~~~~®1"t~tl®91
May zo ion i ^ .
o3 Iowa Department of Transporta ,
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Office of Driver Services !~
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i -NVESTIGATING OFFICERS REPORT
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Park Fair Mall, 100 Euclid Avenue
P.o. Boxs2oa
r OF MOTOR VEHICLE ACCIDENT
Des Moines, Iowa 50306-9204
~\ t Date of Accident Time of Accident County
I Accident occurred within corporate limits of (city)
~ ~ ~ 01/25/09 03:11 Hrs. Dubuque - 3 1 Dubuque - 2100
O If accident occurred outside of city limits
"
"
show general vicinity: "NIA" of nearest city
NIA
C On Road, Street, or Highway: At Intersection wish:
A "N/A" "NIA"
T Note: Unless accident occurred at an intersection which is completely described above, use the space below to give the exact
( location from a milepost or definable intersection, bridge, or railroad crossing, using two distances and directions if necessary,
~ Distance Direction Distance Direction
50 Ft 7-W and 50 Ft 5-S of
N
Milepost Number Definable intersection, bridge, or railroad crossing
"NIA" Or PENNSYLVANIA AND SYLVAN
Driver's Name -Last First Middle Suffix
MERTZ KATHERINE MARIE
Address Ciiy State
IA
770 IOWA STREET DUBUQUE
Date of Birth Driver's License Number Citation Charge Code 1 Citation Charge 1 .
04/05/1979 845222971
Gender State Class Endorsements Restrictions imitation Charge Code 2 Citation Charge 2
Female IA I C I NONE I B Citation Charge Code 3 Citation Charge 3
Alcohol Test Drug Test
Given? Test Results: Given? Test Results: Citation Charge Code 4 Citation Charge 4
1 -None 1 -None
Law Enforcement Case Number.
01-09-3588
Legal Private l
Intervention?^ Property?
Location Literal Description
Off RoadwaylRoadway Not
Found
1
1
X-Coordinate: 00686763
Y-Coordinate: 04707803
~ If Divided Highway, Provide Route
(Cardinal) Travel Direction
"N/A"
Phone
(563) 589-4415 x
Zip
52001
U Seating Position01 I Injury Status 5 I Occupant Protection2 (Airbag Deployment 5 I Airbag Switch Status 9 I Ejection 1 I Ejection Path 1 I Trapped 1
N Transported to: I Transported by
.r I Owner's Name -Last I First
oo,l I Address
770 IOWA STREET
Insurance Co. Name
IOWA COMM. ASSURANCE
VIN No. Year Make
2FAHP71V88X131262 2008 Ford
Initial Travel Vehicle Speed
Direction 4 I Action 09 Limit
Total I Traffic I Vehicle
Occupants 2 Controls 01 Config.
SEQUENCE OF EVENTS I First Event 23
Commercial Trailer Attached to
License Plate # Power Unit:
Carrier Name
Middle I Suffix CITYrOFmDUBUQUE
Cit State Zip 1
DUBUQUE I IA 152001
Insurance Policy # License Plate # State Year
107584 I IA 12009
Model Style Tow # Approximate Cost to
FORD CROWN VICTORIA 4D NO Repair or Replace
Point of Most Damaged Extent of Underride/ Private?
Initial Impact 02 I Area 02 (Damage 2 (Override 1 ^ $100.00
Cargo Body Vehicle Driver Vision Contributing C rcumstances,
i1 I Type 01 I Defect 01 I Condition 1 I Obscured 01 Driver (up to two) 22
Second Event Third Event Fourth Event Most Harmful Event (by vehicle) 23
State Year Attached to State Year Emergency Emergency
Trailer Unit: I Vehicle Type 1 Status 3
Address City State Zip
US DOT # or MC # Number of I Gross Vehicle Placard # I Hazardous Materials
Axles Weight Rating Released?
__ - ~__ __
Driver's Name -Last First Middle Suffix Phone
(5631 582-2258 x
Address City State Zip
Date of Birth Driver's License Number
Gender State Class Endorsements Restrictions
NONE NONE
Alcohol Test Drug Test
Given? Test Results: Given? Test Results:
1 -None 1 -None
Citation Charge Code 1 Citation Charge 1
„itation Charge Code 2 Citation Charge 2
Citation Charge Code 3 Citation Charge 3
Citation Charge Code 4 Citation Charge 4
ll I Seating Position (Injury Status ~ Occupant Protection I Airbag Deployment I Airbag Switch Status
N I Transported to: I Transported by.
T Owners Name -Last First Middle Suffix
NEY I JENNIFER (LEEANN
Cit
0021 3520 PENNSYLVANIA DUBUQUE
Insurance Co, Name Insurance Policy #
VIN No. Year Make
JH4DA9460LS068033 1990 Acura - ACRA
Initial Travel Vehicle Speed
I Point of
Limit
Direction I Action 12 Initial Impact O6
Total Traffic Vehicle Cargo Body
Occupants 0 I Controls 01 Config. 01 Type 0'
SEQUENCE OF EVENTS ~ First Event 23 Second Event
Commercial Trailer Attached to State
License Plate # Power Unit:
Carrier Name ~ Addres
City State Zip
Ejection I Ejection Path I Trapped
1
Owner Company Name 1
State Zip 1
IA 152002
License Plate # State Year
366MTD WI 2009
Tow # Approximate Cost to
NO Repair or Replace
Underride/ Private?
Override 1 ^ $500.00
Vision Contributing Circumstances,
Obscured Driver (up to two) 28
Event Most Harmful Event (by vehicle) 23
State Year Emergency Emergency
Vehicle Type 1 I Status 3
US DOT # or MC # Number of Gross Vehicle Placard #
Axles Weight Rating
Printed At: Dubuque Police Department 01125/2009 05:16 AM Page 1
Model Style
INTEGRA 2H
Most Damaged Extent of
Area 06 Damage 2
Vehicle Driver
Defect 01 Condition 8
Third Event Fourth
Year Attached to
Trailer Unit:
Hazardous Materials
Released? r
Form #: 01-09-3588 ~ ~,
ACCIDENT ENVIRONMENT
Location of First Harmful Event 6 Weather Conditions
Manner of CrashlCollisiori 6 (up to two) 03
Light Conditions 4 Surface Conditions
ROAD WAY CHARACTERISTICS
Major Contributing Circumstances:
Environment 1
Roadway 01
Type of Roadway Junction/Feature 05
WORKZONE RELATED? SEQUENCE OF EVENTS
No
Location First Harmful Event of Crash
Type (use codes 11-42 only) 23
Workers Present?
D
I
A
G
R KEY APT. PARKING LOT
A 3520 PENNSYLVANIA ~~,+
M 1
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NARRATIVE
Describe what happened (refer to vehicles by number)
UNIT 1 WAS BACKING OUT OF A PARKING SPOT IMMEDIATELY ADJACENT TO UNIT 2. UNIT 1 BEGAN TO TURN TO THE
LEFT TOO EARLY AND HIT UNIT 2 ON THE LEFT REAR SIDE CAUSING MINOR DAMAGE TO BOTH VEHICLES.
yy Witness Name -Last First Middle I Suffix
I BAUER BRANDON JOSEPH
T Address City State Zip Code l
N 770 IOWA STREET DUBUQUE IA 52001
E Home Phone # Work Phone #
I
S (563) 589-4415 x
y~ Witness Name -Last First Middle Suffix
I BASTEN DANIELLE M
T Address City State Zip Code l
N 77010WAST. DUBUQUE IA 52001 I
S Home Phone # Work Phone #
g (563) 589-4415 x
Officer Badge No. Time Officer Notified of Accident Time Officer Arrived At Scene
BAUERBRANDON 72 03:11 Hrs. 03:11 Hrs.
Name of Agency Date of Repor[ Investigation T.I. #
Dubuque Police Department 01/2512009 made at scene? Yes
Report Reviewe Dat
e Revie
wed Agency Specific Other Technical Investigation Agency
~ /
/
~tl~l®q DPD
Printed At: Dubuque Police Department 01/25/2009 05:16 AM Page 2 Form #: 01-09-3588
Date: 2/10/2009 01:51 PM
Estimate ID: 30028
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Damage Assessed By: MATT RYAN
Deductible: 0.00
Claim Number: N/A
Owner: JENNIFER NEY
Address: 3520 PENNSYLANNA AVE, DUBUQUE, IA 52002
Telephone: Home Phone: (563) 582-2258.
Mitchell Service: 915702
Description: 1990 Acura Integra GS
Body Style: 2D HB Drive Train: 1.8L Inj 4 Cyl 4A
VIN: JH4DA9460LS068033 License: 366MTD WI
Mileage: 160,398
OEM/ALT: O Search Code: None
Color: RED
Line Entry Labor Line Item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
1 529360 BDY. REPAIR REAR BODY PANEL Existing 2.0*#
2 AUTO REF REFINISH REAR BODY PANEL C 1.8
3 529530 BDY REMOVE/REPLACE REAR BODY DECAL ORDER FROM DEALER 22.25 0.2
4 529780 BDY REMOVE/REPLACE L COMBINATION LAMP ASSEMBLY 33550-SK7-A01 d214.38 0.4
5 530740 REF REFINISH REAR BUMPER COVER C 2.0*
6 900500 BDY * ' ADD'L LABOR OP COVER CAR FOR OVERSPRAY ** QUAL REPL PART 5.00 * 0.2*
7 530750 BDY REMOVE/INSTALL REAR BUMPER ASSY INC
8 530760 BDY OVERHAUL REAR BUMPER COVER ASSY 1.8 #
9 530830 BDY REPAIR REAR BUMPER COVER Existing 2.0*#
10 936014 ADD'L COST FLEX ADDITIVE 5.00 *
11 933000 REF ADD'L OPR TWO TONE 1.0*
12 900500 BDY * REPAIR ATTACH REAR BUMPER Existing 2.0*
13 AUTO REF ADD'L OPR CLEAR COAT 1.1
14 933005 BDY ADD'L OPR RESTORE CORROSION PROTECTION 5.00 * 0.2*
15 AUTO ADD'L COST PAINT/MATERIALS 224.20 *
16 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 4.00 *
* -Judgment Item
# -Labor Note Applies
d -Discontinued by the Manufacturer
C -Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 02/10/2009 13:51:10 30028
Mitchell Data Version: JAN_09_A UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 1 of 2
UltraMate Version: 6.7.019 All Rights Reserved
Date: 2/10/2009 01:51 PM
Estimate ID: 30028
Estimate Version: 0
Preliminary
Profile ID: Mitchell
stirnate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 8.8 60.00 5.00 0.00 533.00 T Taxable Parts 241.63
Refinish 5.9 60.00 0.00 0.00 354.00 T Sales Tax @ 6.000% 14.50
Taxable Labor 887.00 Total Replacement Parts Amount 256.13
Labor Tax @ 6.000 % 53.22
Labor Summary 14.7 940.22
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 4.00 Insurance Deductible 0.00
Sales Tax @ 6.000% 0.24
Customer Responsibility 0.00
Non-Taxable Costs 229.20
Total Additiona l Costs 233.44
I. Total Labor: 940.22
II. Total Replacement Parts: 256.13
III. Total Additional Costs: 233.44
Gross Total: 1,429.79
IV. Total Adjustments: 0.00
Net Total: 1,429.79
This is a areliminarv estimate.
Additional chances to the estimate may be required for the actual reaair.
Insurance Co: CUSTOMER PAY
ESTIMATE RECALL NUMBER: 02/10/2009 13:51:10 30028
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
Page 2 of 2