Claim Gerlach, WilliamCLAIM 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: William Gerlach
2. Address: 738 Kennedy Ct., Dubuque IA 52001
3. Telephone Number: 556 1945
4. Date of Incident: 11 29 02
5. Time of Incident: 02:59
6. Location of Incident (Be specific): On the street of Fenelon
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.)
City Employee, Dale Anthony Rader, was driving a Fire Truck for a
Structure Fire and struck my vehicle in the 700 Block of Fenelon. I was legally parked.
8. What were weather conditions like? Dry, cold.
9. Give name and address of any witnesses: None
10. Did police investigate? (If so, give names of officers.)
Yes, Koch
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.)
Side (Driver Side) of van and driver Rear View Mirror
13. What other damages do you claim, if any?
No
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?
It was a city Truck that hit my vehicle that was legally parked.
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 day of , 20 .
/s/ William J. Gerlach
(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 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: ~k~ ~ L_L~I ~2kk~ ~~--~ ·
2. Address: '-) ~ ~ )~,.~,~t~.~ ~ .~~ .---'~ S~
3. Telephone Number: ~1)
4. Date of Incident: I
5. Time of Incident: ~-~)~ .~ C~
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 was involved, give the
employee's name.)._
!
8. What were weather conditions like? ~ .! ~
9. Give name and address of any witnesses: ~-
10~ pid police i.nvestigate? (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 prope~j 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
com/~ny? (If so, give name and address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
16. Why dO you claim the City of Dubuque is responsible? ~ ~._~ ~ ~ ~
17. Ha~e you made any claim against anyone else for damages as a result of this incident?
(If yes~
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
day of ., 20
(Rev. 1/00 & 7/01)
' "~igna{ure)
(Print Name)
0~ ~= ~=~t of~.s~.~o~ I0 erlt of Trans
P.O.Park Fair Malt. 100 Euctid Aven~eBox 9204 ~ INVESTIGATING OFFICER'S REPORT <~=T~.-~-~'~ ~ .'
PLEASE TYPE OR PRINT Des Moines, iowa ~0306-9204 OF I~OTOR VEHICLE ACCIDENT t.~a]
;~J ~ ~ ~finab~ in~n, ~, ~ mil~d ~g, u~ ~ dls~n~ and d~ E ~.
[~ N ~E~ SE S ~ W ~ F.t M~ N NE E SE S ~ W NW tfD~Hb~y, Pmvide~u~
~N;: ~ ua~ O O O O O O ~ or O O O O O O O O a
O O . T~ ~.~ 4.'~ ~,R~ T~i~ U Z~ ~-R~ O O
o o I I I IIII '~ ~ 11 I1-~
ACQD~ ~IRONME~ RO~WAY C~G~CS WO~ Z~E ~? J J J J J
~c~: O v~ ~ J J l J I F~n~
Name
D x.
Tmnspo~d~:
Da~e of Bir~
Date: 17.~9/2002 12:03 PM
Estimate ID: 7073
Estimate Version: 0
Preliminary
Profile ID: CUSTOMIZED
MIKE FINNIN FORD, INC.
3600 DODGE STREET DUBUQUE, IA 62003
(663) 556-1010
Fax: (563) 690-1086
Tax ID: 42-1874463
Damage Assessed By: PAT GRUTZ
Deductibis: UNKNOWN
Insured: BILL GERLACH
Address: BOX 3381 DUBUQUE, IA 92004
Telephone: Home Phone: (563) 596-1945
Mitchell Service: 01:3528
De_script]on: 1998 Plymouth Voyager SE
BodyStyle: Van113'WB DriveTreln: 3.SLInj6Cyl2WD
VIN: 2p4GP45GSWR596945
Options: 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 Part Type~
item Nund)er Type Operation I:)esc~pfion Part Number
Dollar Labo~
Amount Units
I 300446 BDY REPAIR
2 AUTO REF REFIN~H
3 302106 BDY REMOVE/REPLACE
4 301249 BDY REMOVE/INSTALL
5 301351 BDY REPAIR
6 AUTO REF REFINISH
7 301367 BOY REMOVE/REPLACE
8 303620 BOY REPAIR
9 AUTO REF .~
t0 302997 BDY REMOVE/REP[ACE
11 AUTO REF ADD'L OPR
12 933006 FRM ADD1. OPR
t3 AUTO ADDI. COST
14 AUTO ADDI. COST
L SlOE CAR~O DOOR
L SlOE CARGO DOOR ADHESIVE MLDG PJ89SS8
L QUAE a ti< BOOY SIDE PANEL Existing
L VAN SIDE pANEL OUTSIDE
CLEAR COAT
pAINT/MATERIALS
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
4.5*#
C 2,0
219.00 0.4
0A
C 2A
62.00 0A
6.5*#
C 2,O
22.36 0.2
1.7'
1.5'
226.80 '
4.00 *
ESTIMATE RECALL NUMBER: 12/09/2002 11.29:90 7073
UtiraMate is a Trademark of Mitchell Intemahonal
Mitchell Data Version: DEC 82 A Copy~ght (C) 1994-20~2 Mitchell Internationel
UltraM~e Version: 4.8.012 All Rk3hts Re~enred
Page I of 2
Estimate ID:
Estimate Version:
Pratin~nary
Profile ID:
12/09/2002 12:03 PM
7073
0
CUSTOMIZED
Add'l
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals
Body 17.4 42.~ 0.0~ 0,~ 730.~ T
Refinish 8.1 42.0e O.Oe O.e~ ~4~.2G T
Frame 1.5 50.00 0.00 0.00 75.00 T
Labor Sunanary
III. Additional Costs
Taxable Labor t,146.00
Labor Tax ~ 6.000 % 6~.76
27.0 1,214.76
Non-Taxable Costs
Total Additional Costs
II.
part Replacement Summary
Taxable Parts
Sales Tax ~
Total Replacement Parts Amount
Amount IV. Adjustments
230.80 Customer Responsibility
230.80
Amount
303.35
18.20
321.05
0,00
L Totai Labor:
II. Total ~ parts:
III. Total Additional Costs:
Gross Total:
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional chanqes to the estimate may be required for the actual repair.
1,214.76
321.55
230.80
1~67.~1
0.00
1,767.11
WARNING: Accidental air bag deployment is possible. Personal 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 could
contain an uodepIoyed stage_ Wt~n disposing of a decoyed dual-stage air bag, always treat it as a "live" module.
See appropriate MITCHEU.~ A/R BAG SERVtC~ & REPAIR MANUAL, or OEM inf~'~mUon.
ESTIMATE RECALL NUMBER: 12/09/2002 11:29:50 7073
UitraMate is a Trademark of Mitchell International
Mitchell Data Version: DEC._02_A Copyright (C) 1994 - 2002 Mitchell International
UitraMate Version: 4.8.012 All Rights Reserved
Page 2 of 2
PAGE 2
t[.~tim~ Vcmiol~: 0
Profile ID: Mitchell
Riley's Olds-Mazda-Subaru
4455 r~,dge'$t.'~Jbuque, IA 52003
Fax: (~,~)
Tax ID: 42-0~57~'77 EPA~: 1AD05'10031~
In~uzed; BILL GERLACH
Ad~re=s: I~OX 3381 DU~UQUE~ IA 54004
Telephone; Hom~Pho~e: (563)S~-1~45
Mitchell S~r~ce: ~'13~25
Description: 1998 Plymouth Voyager SE
Body S~l~: Van ~ 13"~ Dfi~ T~: 3~L Inj 6 Cyl 2WD
VIN:
TiLY S~ER~G WHEE~ CRUISE ~N~OL, ~M ST~EO, AUTO~TIC
Line EntO' Lebor Ur~ Item Part ?)'IPJ Dollar ~bor
2 ~TO ~F" ' ~N~ L ~NDER 0g~ C 2,0
~ ~O6 BOY ~EMO~R~ L ~T~OOR P~ MIRROR 4~17~01AB 2~.~
· . ~1~ ~O~ '~MOV~INST~L. LF~TDOOET~MFAN~ 6,4
6 AUTO ' ~F ~FIN~H L ~[DE CARGO ~ C
7 ~t~7 BDy , ~OV~REP~CE L SIDE ~O ~.~H~E ML~G P~8 62.00
9 AUTO REF ~FIN~H L V~ SIDE P~EL ~iDE C
10 30~7 B~ ~OVE~REP~E L QUeeR ~H~E M~ING P~$8 2~35
tl AUTO ~F ~D*L OPR C~AT 1.7
13 A~O ~'L ~ST ~DOUS W~TE D~PO~L 4.~ *
' - Judgement .item
# - Labor.Note Appiie~
C - Included in Clear Coat Cale
PAGE
Estimate ID: 4929
pn=limina~y
Profile ID: Mitchelt
· Labor ~.~blet
· T,~x~ Costs
Sete~ Tax
Non-Taxable ~
1,24~.$$
Il. P~rt Replacement Sum mary
Taxable Parts
~ales Tax ~
Total Replacement Pelts Amount
Am0~nt IV, A~justmen~s
21~.70
6.900%
A~ount
0.00
TetaJ Additk~ nat
L Total labor:.
iL Total Replacement Pans:
Gross Total:
1~46.56
222.99
~. To~lA~ustmen~;
N~TOtah
1,791.10
This is a Drel!minarv estiRl,ate.
_Add~o.n. al ~hanaeS f~ the e~im~ate may be required for the actual reoak.
THis DAMAG~ RE~ORH IS .BASED ON ~ INS~E~ION ~ DO~S NOT C0~R ~
~N O~ED ~ ~ !NS~CE C~P~ '~ BE ~IFI~.
LIF~TII~g PAZbTT, PERFO~/42LNCE GUARANT~gE USING F. PPROVE~D PPG ~/qD A
THREE YF~%R GUARNArI~E ON OVERALL WORKMANSHIP IS %~ALID FOR AS
LONG A~ YOU OWN THE VEHICLE STATED HE~iN.
Page 2 ot 2