Claim, Krieg, Carol B.CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
This written report constitutes' your claim against the City of Dubuque, Iowa.
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 su.b. mitted to the
City Council. ~-e provided with a copy of that report and recommendation.
THE FINAL DEC'ON ON; ALL CLAIMS IS MADE BY THE ~C~TY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKi~ANY REPRESENTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PA~.
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 emplo~.ee wa~s involved, give the
employee's name.) , ~ , ~ ~
8 Wh,t were weather oonditions like? ¢/¢¢~
9. 6ive name and address of any witnesses:
10. Did ~/~te 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.
t~tach estimates of damages or describe basis for ascertaining extent of damage.)
13. What other damages do you claim, if any?/~_ .~/~/~:~k?_ ~--7~.
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?~-~o~X~ ~/~/~/~: ;~/~ ·
- - · -
~6. Why do you claim the City of Dubuque is responsible? ~''
'~7. 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?
(Rev. 1/00 & 7/01)
Date: 10/2t/02 03:34 PM
Estimate ID: 7296
Estimate Version: 0
Preliminary
profile ID: CUSTOMIZED
OWNER STATES SINCE ACCIDENT REAR SHOCKS DO NOT SEEM TO WORK ALSO
RF2~R OF UNIT SHAKES
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(563) 583-9t 2t
Fax: (563) 556-4482
Tax ID: 42-0400210
Damage Assessed By: JOHN KLOTZ JR.
Deductible: UNKNOWN
Owner CAROL KRIEG
Address: 708 RIES DUBUQUE, IA 52001
Telephone: Home Phone: (563) 557-0557
Mitchell Service: 918490
Description: 1993 Chevrolet Cavalier VL
Body Style: 2D Cpe Drive Train: 2.2L Inj 4 Cyl 3A
VIN: t G1JC¶446P7345655
Options: AIR CONDITIONING, POWER STEERING, ELECTRIC DEFOGGER, AM-FM STEREO
AUTOMATIC TRANSMISSION
Una Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
1 845010 BDY REMOVE/REPLACE L QUARTER OUTER PANEL 22554559 GM PART
2 AUTO REF REFINISH L QUARTER PANEL OUTSIDE
3 AUTO REF REFINISH L LOCK PILLAR
4 AUTO REF REFINISH L QUARTER PANEL EDGE
8 846200 BDY REMOVE/REPLACE L QUARTER ADHESIVE MOULDING ORDER FROM DEALER
6 851030 SDY REMOVE/REPLACE LUGGAGE LID PANEL 22565645 GM PART
7 AUTO REF REFINISH LUGGAGE UD OUTSIDE
8 AUTO REF REFINISH LUGGAGE UD UNDERSIDE
9 861150 BDY REMOVE/REPLACE LWR LUGGAGE UD FINISH PANEL 22570536 GM PART
10 851230 BDY REMOVEAREPLACE LUGGAGE LID NAMEPLATE 22572190 GM PART
11 851300 BDY REMOVE/REPLACE LUGGAGE LID NAMEPLATE 22572187 GM PART
12 853520 MCH ALIGN CHECK REAR SUSPENSION -M
¶3 853530 MCH AUGN FRONT SUSPENSION
14 855340 BDY REMOVE/REPLACE REAR BODY PANEL 20631614 GM PART
15 AUTO REF REFINISH REAR BODY PANEL
16 AUTO REF REFINISH ADD FOR INSIDE
17 AUTO BDY OVERHAUL REAR COVER ASSY
18 858810 BDY REMOVE/REPLACE REAR BUMPER COVER 22548855 GM PART
19 AUTO REF ADD'L OPR CLEAR COAT
20 AUTO ADD'L COST pAINT/MATERIALS
21 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
Dollar Labor
Amount Units
474.10 14.5 #
C 2.4
C 0.5
C 0.5
53.19 0.'t
507.66 1.5 #
C 1.9
C 1.2
140.78 INC
19.63 INC
'19.63 INC
0.8
0.5
98.39 4.8 #
C 1.1
0.8
t.3 #
183.66 INC
2.2
27[60 *
6~00 *
ESTIMATE RECALL NUMBER: 10/21102 15:29:59 7296
UltraMate is a Trademark of Mitchell International
Mitchell Data Vemion: OCT_02_A Copyright (C) 1994- 2002 Mitchell International
UltraMste Version: 4.8.01t All Rights Reserved
Page I of 2
* - Judgement Item
# - Labor Note Applies
C - included in Clear Coat Calc
Date: 10121102 03:34 PM
Estimate iD: 7296
Estimate Version: 0
prsliminary
Profile ID: CUSTOMIZED
Add'l
Labor Sublet
1. Labor Subtotals Units Rate Amount Amount Totals
Body 21.9 45.00 0.00 0.00 985.50 T
Refinish 10.6 45.00 0.00 0.00 477.00 T
Mechanical t.3 52.00 0.00 0.00 67.60 T
Taxable Labor 1,530.10
Labor Tax ~ 6.000 % 9t.81
Labor Summary 33.8
Ill. Additional Costa
Non-Tax. able Costs
Total Additional Costs
1,621
Amou~
281.~
281~0
II. Part Replacement Summary
Taxable parts
Sales Tax
Total Replacement Parts Amount
IV. Adjustments
Customer Responsibility
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
Amount
1,494.01
6.000% 89.64
1,583.65
Amou~
0.00
1,621.91
1,583.65
281.60
3,487.16
Total Adjustments:
Net Total:
0.00
3,487.16
This is a preliminary estimate.
Additional chan.qes to the estimate may be required for the actual repair.
PARTS PRICES ~ SUBJECT TO C~AtqG~
WARNING: AcckJental 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 undeplayed stage. When disposing of a deployed dual-stage air bag, always treat it ss a "live" module.
See'ap~propriste MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM information.
ESTIMATE RECALL NUMBER: 10121102 15:29:59 7296
UifraMste is a Trademark of Mitchell Intemational
Mitchell Data Version: OCT._02_A Copyright (C) 1994- 2002 Mitchell International
UifmMate Version: 4.8.011 All Rights Reserved
Page 2 of 2
Style:
Color:
Color Code:
Production Date: / 0
License: State: IA
VIN:
Miles In: 0
Miles Out: 0
Condition:
Estimator: BRIAN
Date Assigned: 10/19/02
Federal Tax ID: 42-1504933
Estimate 770 CEDAR CROSS ROAD Customer No: 220
Dubuque, IA 52003 Report No: 209
10/t9/02 Phone #: (563) 582-~725 Claim ~..
Fax #: (563) 586-1244 Assign No:
E-Mail: BMILLER20 OL.COM
Vehicle Information
1993 Chevrolet Cavalier Owner. CAROL KRIEG
Accident Location
Dubuque, IA 52003
Home Phone: (563)
Work Phone: (5~3) Phone #1:
Fax ~. (563) Phone ~2:
Insured -
Claimant
Home Phone: (563) Home Phone: (563)
Work Phone: (563)
Fax ~ (563) - Work Phone: (563)
Date of Loss: 10/19/02 Fax #: (563) -
---J~.r~rk Date of Inspection 10/19/02
Other o~erations '
* REAR QTR CLIP USED Part Number Price Labo Paint Other
+Edging (1.5) +Clearcoat (3.0*) $400.00 *
20.0' body* 10.0'
4.5
FREE LOANER CAR Sub Totals
THANK YOU FOR LETTING US SERVE YOU
-- Hours Rate Tots,
Body Labor 20.0hfs $42.00/hr $840.00
Paint Labor 11.5hrs $42.00/hr $483.00
Clearcoat Labor 3.0hfs $42.00/hr $126.00
OEM Parts
$4O0.00
Paint Supplies 11.5hrs $24.00/hr $276.00
Clearcoat 3.0hfs $24,00/hr $72.00
Tax
Grand Total $1849.00 @ 8.0000% $110.94
$2,307.94
Estimate based on MOTOR CRASH GUIDE (DE1CL88k
' HABERKORN AUTO CENTER 5-T2
602 PERU ROAD - DUBUQUE. IOWA52001 · PRONE (319) 556-8872
OWNER ADDRESS DATE S/~)
FRONTOFCAB ~¥ uas. su~c~ PARTS L~SIDE ~ u~ s~ PA~S RIGHTS,DE ~ u~s ~R~ PARTS
BUMPER H~DL]G~ HEADLIGHT
DUMPER BRKT. COMPOSITE COMPOSITE
BUMPER GUARD
GRILL PARKING, LIGHT PARKING, LIGHT
GRILL FENDER, FRONT FENDER, FRONT
GRILL M~G. FENDER, APRON FENDER, APRON
FENDER M~G. FENDER MLDG.
GRAVEL SHIELD FENDER M~G. FENDER MLDG.
WINDSHIELD FENDER MLDG. :ENDER MLDG.
H~DER PANEL FENDER MLDG. FENDER MLDG.
DOOR, FRONT DOOR, FRONT
COWL DOOR, MLDG. DOOR, MLDG.
RAD. SUPPO~ DOOR G~SS DOOR G~SS
~D. CORE VENT G~SS VENT GLASS ,
A~IFREEZE CENTER POST CENTER POST
FAN B~DE
FAN SHROUD DOOR, R~R DOOR, R~R
DOOR, MLDG. DOOR, MLDG.
DOOR G~SS DOOR GLASS
HOOD
HOOD HINGES
HOOD MLDG. ROCKER PANEL ROCKER PANEL
ROCKER MLDG. ROCKER MLDG.
FLOOR FLOOR
ORNAMENT 1/4PANEL ~ ~,~ q.~ ~ ~0 1/4PANEL
1/4PANE~ ~ ¢~ /~ ~a 1/4PANEL
NAME P~TE
LOCK P~TE, LR. 1/4 PANEL~ 1/4 PANEL
LOCKSUPT. WHEELHOUSE ~ ~ ~,~ WHEELHOUSE
I/4 MLDG. 1/4 MLDG.
REAR OF CAR
TAILLIGHT TAILLIGHT
TAI~IGHT TAILLIGHT
GRAVEL SHIELD TAILLIGHT TAiLLiGHT
LOWERPANEL ~ ~,~ r~ BACK-UPLIGHT BACK-UPLIGHT
FLOOR BACK-DP LIG~ BACK-UP LIGHT
TRUNKLID ~ ~ /'~ ~ ~ CLEARCOAT ~
TRUNKHINGE ~ (~ //~ ~ ~ ~ CLaN-UP.
~ ~ ~ ~ '~e ~d MISC. ITEMS PARTS~
- TOP tDE~IFICATION PAINTING
LICENSE LIGHT F~ME KEY TOWING
~ES UATER~A~
HUBS CAPS R REPAIR wAsm
WHEEL DISC. OH OVERHAUL
.ESTIMATE