Claim, Paradiso, Jim & KarenCLAIM 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: Jim & Kim Paradiso
2. Address: 595 Alta Vista St.
3. Telephone Number: (563) 556 8537
4. Date of Incident: 10-14-02
5. Time of Incident: 11:00 A.M.
6. Location of Incident (Be specific):
Right hand side of Delhi Street Approximately 1303 Delhi
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.)
A note was left on my Safari telling me that Keyline Bus #2567 hit me @ approximately 11:00 a.m. - 1303 Delhi, copy of note is attached
8. What were weather conditions like? Good
9. Give name and address of any witnesses:
SEe attached note.
10. Did police investigate? (If so, give names of officers.)
No
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
No
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.)
Left hand mirror bent back and broken - estimates attached
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?
16. Why do you claim the City of Dubuque is responsible?
Because a Keyline bus hit the mirror
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 16 day of October , 2002.
/s/ Kimberly M. Paradiso
(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 att~h 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: ~_~7~ vv~ -~
2. Address: ~ ~ C~-~ ~
3. Telephone Number: ~_L~ ~
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.
employee's name.)
t
If a City employee was involved, give the
J
8. What were weather conditions 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 damag6s.
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,)
15. What amount do you claim from the City of Dubuque?
16. W~hy 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.) ~/O/C/
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
(Rev. 1/00 & 7/01)
day of _~7-7J~ , 20 ~.
Periostat C~~ ~..., .....
(doxycycline hyclate)~=. ,.,
FED ID #42-0813744
Data: 10/16/2002 01:46 PM
Estimate ID: 7207
Estbnata Version: 0
Preliminary
Profile ID: Mitchell
RICHARDSON MOTORS
1476 J.F.K. ROAD DUBUQUE, IA 62002
(663) 582-5411
Fax: (663) 682-4129
Damage Assessed By: AJ- COGHLAN
Deductible: UNKNOWN
Owner JIM pARARDISO
Address: 696 ALTAVISTA DUBUQUE, IA 52001
Telephone: Home Phone: (663) 566-8537
Mitchell Service: 91M84
Description: 1997 OMC Salad SLT
Body Style: VanPassExt 111" WE; Drive Train: 4.3L Inj 6 Cyl 4WD
VIN: 1GKELt~W6VB505283
Options: 4WD OR AWD, 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
item Number Type Operation Description
I 616860 BDY
2 5,33564 BDY
REMOVE/REpLACE L FRT DOOR POWER MIRROR
REMOVE/INSTALL L FRT DOOR TRIM PANEL
Part Type/ Dollar Labor
Part Number Amount Units
16001801 GM pART 179.80 0.3 #
0.4
# - Labor Note Applies
I. LaborSuMotais UnIts
Body
Add'i
Labor Sublet
Rate Amount Amount
Totals
0.7 45.00 0.00 0.00 31.60 T
Taxable Labor 31.50
Labor Tax ~ 6.000 % 1.89
8.7 33°39
III. AddItional Costs Amount
Total Additional Costs 0.00
IL
Part Replacement Summary
Taxable Parts
Sales Tax ~
Total Replacement Pa;ts Amount
IV. Adjustments
Customer Responsibility
6.000%
Amount
179~;0
10.79
190.59
Amount
O.00
ESTIMATE RECALL NUMBER: 10/15~002 13:43:31 7207
UltraMate is a Trademark nt Mitchell International
Mitchell Data Version: OCT_02_A Copyrignt (C) 1994 - 2002 Mitchell intemetionel
UltraMete Version: 48.011 All Rights Reserved
Page I
of ~
Date: 10/16f2062 01:46 PM
Estimate ID: 7207
Estimate Version: 0
Preliminary
profile ID: Mitchell
I. Total Labor: 33.39
IL Total Replacement Parts: 190.99
III. Total Additional Costs: 0.00
Gross Total: 223.98
IV. Total Adjustments: 0.90
Net Total: 223.98
This is a preliminary estimate.
Additional chanqes 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 pane] even if air bags have deployed. Duat -atage air bag modules may be present that could
contain an undeployad stage. When disposing of a deployed dual-stage air bag, always t~eat it as a "live" module.
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM information.
ESTIMATE RECALL NUMBER: 10115/2002 t3:43:31 7207
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: OCT_02_A Copyright (C) 19~4 - 2002 Mitchell International
UltraMate Version: 4.9.911 All Rights Reserved
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