Claim, Gross, TerryCLAIM 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: T erry Gross
2. Address: 503 Arlington St.
3. Telephone Number: 557 3067
4. Date of Incident: 11 12 02
5. Time of Incident: 0808
6. Location of Incident (Be specific):
Arlington & Highland Place
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.)
My parked truck was hit by Carole Ann Stahl resulting in damage to my truck.
8. What were weather conditions like?
Clear
9. Give name and address of any witnesses:
Myself and the otehr employee with Carole Anne Stahl, I don't know this person's name.
10. Did police investigate? (If so, give names of officers.)
Yes, Reimer.
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.)
The left rear taillight is broken and a huge dent on the left side of the liftgate. The liftgate won't open because of the accident.
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? $1511.95 - we prefer the work to be done at Ford.
Because it was a City employee and vehicle that caused the damage.
16. Why do you claim the City of Dubuque is responsible? Because it was a city employee and vehicle that caused the "damage."
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 14 day of November, 2002.
/s/ Terry Gross
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM AGAINST THE CITY OF DUBUQUEi~-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:
2. Address:
3. Telephone Number: ~-~-r-] _ ~ 0/~ ~'~
4. Date of Incident: //--/--~ --0 ~-
5. Time of Incident: ~ ?~
6. Location of Incident (Be specific):/r~//~/~Z~
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE.
full details upon which you base your claim. If a City employee
.e/~?ployee's name.) .
(Give
was involved, give the
8. What were weather conditions like? ~//~ r~
9. Give name and address of any witnesses: Byl~e~/~2 ~f~J ~J~_
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, give name and address of insurance company and amount paid.)
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?
Dated at Dubuque, Iowa this
~(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
A~rro ACC:rDE~ ~-~OE,t",A'n:O~ d~ ~--3'-2 !~ /
LOCA~TON
D~- OF BZR~I
DRIvI~t* S NAttE
Dc~~ /~
STATE ZIP CODE
STATE '£~rE ~S~I
ZIP CODE
~D~SS
V~I~ELIC~SE
STATE/YEAR
V~ttlCLE tlAKS
INVESTIGATIJ~ OleFICER(S) RanGE NO.
Date: 1111312002 03:58 PM
Estimate IO: 6971
Estimate Versk~: 0
Prel~ninary
Profile ID: Mitchell
MIKE FINNIN FORD, INC.
3600 DODGE STREET DUBUQUE, IA 62003
(963) SS6-101e
Fax: (563) 690-1086
Tax ID: 42-1074463
Damage Assessed By: PAT GRUTZ
Deductible: UNKNOWN
Insured: TERRY GROSS
Address: $03 ARLINGTON ST DUBUQUE, IA 02001
Telephone: Home Phone: (663) $97-3067
Mitchell Service: 918622
Description: 199~ Ford Explorer XLT
Body Style: 4D Ut 112" W~ Drive Train: 4.0L Inj 6 Cyl 4WD
VlN: IFMZU34XXWZB27567
Options: AIR CONDITIONING, PO1N~R STEERING, POWER BRAKES, POWER WINDOWS, POWER DOOR LOCKS
TILT STEERING WHEEL, CRUISE CONTROL, AM4:M STEREO, AUTOMATIC TRANSMISSiON
Line Entry Labor Line Item Part Type~
[tent Number Type Operation Desoript~on Part Number
Dollar Labor
Amount Units
I 803403 BDY REMOVEaREPLACE
2 AUTO REF REFINISH
3 AUTO REF REFINISH
4 802890 BDY REMOVE/REPLACE
6 802902 BDY REMOVE/REPLACE
6 802165 BDY REMOVE/REPLACE
7 AUTO REF ADD'L OPR
8 933005 BDY ADD'L OPR
9 933018 REF ADD~. OPR
10 AUTO ADD'L COST
11 AUTO ADD/. COST
LIFTGATE SHELL
LIFTGATE
ADO FOR JAMBS 8, INSIDE
LIFTGATE ADHESIVE NAMEPLATE
LIFTGATE ADHESIVE NAMEPLATE
L COMBINATION LAMP ASSEMBLY
CLEAR COAT
RESTORE CORROSION PROTECTION
MASK FOR OVERSPRAY
PAINTIMATERIALS
HAZARDOUS WASTE DISPOSAL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
XL2Z 7840010 AA
F87Z 7842528 PA
F87Z 7842528 RA
F87Z 13406 AC
621.00 5.6 # C 2,8
C 1.0
18.87 0.1
12.20 0.1
70.80 0.3
1.6
15.60' 0,2*
16,00' 0,3*
148,40 *
2.65 *
ESTIMATE RECALL NUMBER: 1t/t3/2002 15:49.23 6971
UitraMate is a Trademark of Mitchell Intetnafionel
Mitchell Data Version: NOV_O2_A Copyright (C) 1994 - 2002 MItchell International
U[traMate Version: 4.8.012 All Rights Reserved
Page I of 2
Date: 11/13/2002 03:58 PM
Estbnats ID: 6971
Estimate Version: 0
Prelkaenary
Profile ID: Mitchell
IlL
Add1
Labor Sublet
Labor Subtotals Units Rate Amount Amount Totals
Body 6.2 45.00 15.00 ILO0 294.00 T
Refinish 5.6 45~0~ t5.00 0.00 267.00 T
Taxable Labor 561.00
Labor Tax ~ iLO00 % 33.66
Labor Summary
Additional Costs
11.8 594.66
Non-Taxable Costs
Total Additional Costs
151.05
151.05
Part Replacement Sunmmry
Taxable Parts
Sales Tax ~
Total Replacement Parts Amount
Customer Responsibility
6.000%
722.87
43.37
766.24
Amount
iL00
L Totae Labor:
IL Total Replacement Pints:
IlL Total Additionae Costs:
Gross Total:
IV, Total Adjustments:
Nnt Total:
594~6
766.24
151.05
1~11~$
0.00
1,511.95
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
Insurance Co: CITY OF DUBUQUE
WARNING: Accidental air bag deployment is possible. Personae injury may result. Avoid area near steering wheel
and instrument panel even if air bags have deployed. Duet-stage air bag modules may be present that c~Id
contain an undeployed stage. When disposing of a deployed deal-stage air hag, ahvays treat it as a 'liw~~ [nodule,
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM tafomtatior~
ESTIMATE RECALL NUMBER: 11113/2002 15-.49:23 6971
UitraMete is a Trademark of Mitchell Intarnational
Mitchell Data Version: NOV_02_A Copyright (C) 1994 - 2002 Mitchell International
UltraMete Version: 48.012 All Rights Reserved
Page 2
of 2
Date: 11/14/02 01:10 PM
Estimate ID: 3919
Estimate Version: 0
Prome ID: CUSTOMIZED
Dan Kruse Pontiac, Nissan, BMW
Deductible: UNKNOWN
TERRy GROSS
503 ARUNTON DUBUQUE, IA 52001
Home Phon~ (563)557-3067
Add~ess:
Telephone:
Century Drive Dubuque, IA 52002
(663) 6834'346
Fax: (663) 688-.387,4
lY. scrip~oa: ~ Ford Explorer XLT
Body Slyle: 4D Ut 112' W~
VIN: 1FMZU34XXWZB27567
Mitchell Service: 918622
DAVE DeMOSS
Body Shop Manager
DAN KRUSE PONTIAC-NISSAN, INC.
600 Century Drive
Dubuque, Iowa 52002
Bus. (563) 583-7345
Toll Free 1-$00-373-CARS
Drive Train: 4.0L Inj 6 Cyl 4WD
Options: AIR CONDITION~, POWER STEER~IG, POWER BRAKES, POWER ~, POWER DOOR LOCKS
TILT STEERING WHEEL, CRUISE CONTROL, AM-FM STEREO, AUTOMATIC TRANSMISSION
Line Ent~ Labor Line ~ Pa~t Type/
item ~ Type OperaUon Description Part N~
1 803403 BDY REMOVE/REPLACE UFTGATE SHELL XL2Z 78400'1~ ~
2 AUTO REF REFINISH LFTGATE
3 AUTO REF REFINISH ADD FOR JAMBS & INSIDE
4 802890 BDy REMOVE/REPLACE UFTGA1E ADHESIVE NAMEPLATE F87Z 7842528 PA
$ 802902 BDy REMOVE/REPLACE MFTGATE ADHESIVE NAMEPLATE FS?Z 7842528 RA
6 802165 BDy REMOVE/REPLACE L COMBINAllON LAMP ASSEMBLY F87Z 13405 AC
7 AUTO REF ADlYL OPR CLEAR COAT
8 AUTO ADD~ COST PAINT/MATERIALS
9 AUTO ADOI_ COST HAZARDOUS WASTE DISPOSAL
.~ I. hdts
621~00 $.5 #
* - Judgement item
# - Labor Note Applies
C - Included in Clear Coat Calc
C2.8
C 1.0
1887 0.1
12.20 0.1
70.80 0.3
1.5'
132.50 *
3.50 *
Acid1
Labor Sublet
L Labor Subtotals Units Rate Amount A~ount Totals
Body 6.0 42.00 0.00 0.00 252.00 T
Refinish 6.3 42.00 0.00 O.00 222.60 T
Taxable Labor 474.60
Labor Tax ~ 6~ % 28A8
LaborSummmy 11.3 503.08
11. Parl: Replaceme~ S~, m ~ry
Taxable Parts
Sales Tax ~
Total Replacemeat Parts Amount
ESTIMATE RECALL NUMBE~ 11/14~2 13:03:53 3919
UltraMate is a Trademark of Mitchell Interna{/o. al
Mitchell Data Version: NOV_O2_A CopyrigM (C) 19~4 - 2002 Mitchell IntemaUonal
UltraMate Version: 4.8.012 NI Rights Reserved
Page I
Date: 11/14/02 01:10 PM
Eslimate ID: 3919
Estimate Version: 0
Preliminary
Profile ID:. CUSTOMIZED
Amount IV. Adjus~r~r~s
1~.00 Custom~ Responsibility
136.00
0.00
L Total Laboc.
II. Total Replacement Pa-ts:
IlL Total Add~ional Costs:
Gross
This is a preliminaw estimate.
Additional chanqes to the estimate may be required for the actual repair.
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER AN~ ADDIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER
THE WORK HAS BEEN OPENED UP Tm INS,WILL BE NOTIFIED.
WE FEATu~.E A T~REE 1'EAR WORKMANSHIP LIMITED ~- SEE OUR WRITTEN
~ FOR COMPLETE DETAILS. (EFECTIVE 10-01-01)
7~4
1~0~
0.00
1,405.32
WARKqNG: Accident;d ~r bag deployment is possible. Personal inju;y may resutt. Avoid area near steering wheel
and ~mtrument panel even/f air bags have deployed. Dual-stage air bag modules may be present that could
contain an undeployed stage. When disposing of a deployed dual-stage air bag, always treat it as a 'l'we' module.
See appropriate MITCHEU.~ AIR BAG SERVICE & REPAIR MANUAL, or OEM infonlnaUon.
ESTIMA'I~ RECALL NUMBER: 11/t4/02 13:03'53 3919
UltraMate is a Trddemark of Mitchell International
Mitchell Data Version: NOV_02_A Copyright ~C) 1994 - 2002 Mitchell international
UltraMate Version: 4.8.012 All Rights Reserved
Page 2 of 2