Claim Krieg, Carol B. 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 submitted to the
City Council. ~e prov~ed with a copy of that report and recommendation.
2. Address: ~/O
3. Telephone Number:
THE FINAL DECISI~--ON ON,'ALL CLAIMS IS MADE BY THE ~ITY 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~.
4. Date of Incident: il.,
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 employee wa~s involved, give the
employee's name.) .
,'/'V o r e.K
-- - ' ' -
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.
~d~tach estimates of damages or describe basis for ascertaining extent of damage.)
~ ~.~ j
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[~5_~5~ ~'c/d° you claim from the City of Dubuque? J~-'~,_ ~o ~' .~//,~,' ~_~..~L
7 5~ ~I~{ ~ ~;~ ~rl ~ ~
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?
day of_."~ _~'/ _ . ~ ,.20
-- ¢ignaturd -
(Print
(Rev. 1/00 & 7/01)
Date: 10121/02 03:34 PM
Estimate ID: 7296
Estimate Version: 0
Preliminary
Profile ID: CUSTOMIZED
~WNER STATES SINCE ACCIDENT PEAR SHOCKS DO NOT SEEM TO WORK ALSO
REaR OF UNIT SHAKES
BIRD CHEVROLET
3255 UNIVERSITY AVE. P.O. BOX 57 DUBUQUE, IA 52001
(563) 583-9t 2t
Fax: (563) ,656.-4482
Tax ID: 42-0400210
Damage Assessed By: JOHN KLOTZ JR.
Deductible: UNKNOWN
Owner CAROL KRIEG
Address: 708 PJES DUBUQUE, IA 52001
Telephone: Home Phone: (563) 557-0557
Mitchell Service: 918490
Description: 1993 Chevrolet Cavalier VL
Body Style: 2D Cpe D~'ive Train: 2.2L Inj 4 Cyl 3A
VIN: 1GIJC1446P7345655
Options: AIR CONDtTIONING, POWER STEERING, ELECTRIC DEFOGGER; AM-FM STEREO
AUTOMATIC TRANSMISSION
Line Entry Labor Line Item Part Type/
Item Number Type Operation Description Part Number
Dollar Labor
Amount Units
I 849010 BOY 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
5 846200 BDY REMOVE/REPLACE L QUARTER ADHESIVE MOULDING ORDER FROM DEALER
6 851030 BDY REMOVE/REPLACE LUGGAGE LID PANEL 22565645 GM PART
7 AUTO REF REFINISH LUGGAGE LID OUTSIDE
8 AUTO REF REFINISH LUGGAGE LID UNDERSIDE
9 851150 BDY REMOVE/REPLACE LWR LUGGAGE LID FINISH PANEL 22570536 GM PART
10 851230 BDY REMOVE/REPLACE 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
13 853530 MCH ALIGN FRONT SUSPENSION -M
14 855340 BDY REMOVE/REPLACE REAR BODY PANEL 20631614 GM PART
t5 AUTO REF REFINISH REAR BODY PANEL
t6 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 ADG'L COST HAZARDOUS WASTE DISPOSAL
474.t0 t4.5 #
C 2.4
C 0.5
C 0.5
53.19 0.1
507.66 t.5 #
C 1.9
C 1.2
140.75 INC
19.63 INC
19.63 tNC
0.8
0.5
95.39 4.5 #
C 1.1
0.8
1.3 #
183.66 INC
2.2
275.60 *
ESTIMATE RECALL NUMBER: 10/2'1102 15:29:59 7296
UltraMete is a Trademark of Mitchell International
Mitchell Data Version: OCT_02_A Copyright (C) 1994 - 2002 Mitchell Intemettenal
UltraMete Version: 4~8.011 All Rights Reserved
Page t of 2
MILLER AUTO BODY
Federal Tax ID: 42-1504933
Estimate 770 CEDAR CROSS ROAD Customer No: 220
Dubuque, IA 52003 Report No: 209
10/19/02 Phone #: (563) 582-5725 Claim ~
Fax #: (563} 585-1244 Assign No:
E-Mail: BMILLER20 - OLCOM
Vehicle Information ~
1993 Chevrolet Cavalier
Style:
Color:
Color Code:
Production Date: / 0
Lioense: StYe: IA
VlN:
Miles In: 0
M/les Out: 0
Condition:
Estimator: BRIAN
Date Assigned: 10/I 9/02
Descri 'on of Work
Other o~erations
* REAR QTR CLIP USED
+Edging (1.6) +Clearcoat (3.0*)
Owner. CAROL KRIEG Accident Location
Dubuque, IA 52003
Home Phone: (563) -
Work Phone: (553) - Phone #1:
Fax #: (563) Phone
Insured -
Claimant.
Home Phone: (563)
Work Phone: (563)
Fax#: (563)
Date of Loss: 10/19/02
Home Phone: (563)
Work Phone: (563)
Fax#: (563) -
Date of Inspection: 10/19/02
$400.00 * 20,0* body* 10.0'
4.5
FREE LOANER CAR Sub Totals
THANK YOU FOR LETTING US SERVE YOU
Hours Rate Total
Body Labor 20.0hfs $42.00/hr $840.00
Paint Labor 11.5hfs $42.00/hr $483.00
Clearcoat Labor 3.0hfs $42.00/hr $126.00 ?
OEM Parts $400.00 /-
Paint Supplies 11.Shrs $24.00/hr $276.00
Clearcoat 3.0hfs $24,00/hr $72.00
Tax $1849.00 @ 6.0000% $110.94
Grand Total
$2,307.94
. E~timate based on MOTOR CRASH GUIDE (DE1CL88}
Ind~ates Estimator's Judgment . ;3&72
'~ Indlcate~ Taxed Item
Page '~ o~1
OWNER
FRONT OF CAR
BUMPER
BUMPER SRKT.
BUMPER GUARD
HABERKORN AUTO CENTER
ADDRESS
pARTS LEFT SIDE
PARTS
' SiDE
HEADLIGHT
COMPOSITE
LIGHT
PARKING, LIGHT
GRILL FENDER, FRONT
FENDER, FRONT
GRILL
GRILL MLDG. FENDER MLDG.
FENDER MLDG.
FENDER MLDG.
FENDER MLDG.
GRAVEL SHIELD
FENDER MLDG.
WINDSHIELD MLDG.
FENDER MLDG.
HEADER PANEL FRONT
DOOR, FRONT MLDG.
DOOR, MLDG.
COWL DOOR GLASS
DOOR GLASS
RAD. SUPPORT ~LASS
' GLASS
RAD, CORE
REAR OF CAR
ANTIFREEZE
FAN BLADE
FAN SHROUD
HOOD
HOOD HINGES
HOOD MLDG.
ORNAMENT
NAME plATE
LOCK PLATE, LR,
LOCK SUPT.
BUMPER
BUMPER GUARD
PARTS
DOOR, REAR
DOOR, MLDG.
DOOR GLASS
~POST
DOOR, REAR
DOOR, MLDG,
DOOR GLASS
ROCKER PANEL
1~ PANEL
=ANEL
PANEL
[ELHOUSE
4 MLDG.
ROCKER PANEL
ROCKER MLDG.
FLOOR
4PANEL
/HEELHOUSE
TAILLIGHT
--GRAVEL SHIELD
LOWER PANEL
FLOOR
TRUNK LtD
TRUNK HINGE
LICENSE LIGHT
~UGHT
=UGHT
TOP
HUBS CAPS
DISC.
MISO. ITEMS
~ LIGHT
= LIGHT
COAT
LABOR
N NEW
R REPAIR
OH OVERHAUL
A ALIGN
p PAINT
S SUBLET
HRS.@
PARTS
TAX
ESTIMATE