Claim Gassman, Brooke N. CLAIM AGAINST THE
This written report constitutes your claim
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: ~¢~0~x~b ~.
2. Address:
3. Telephone Number:
4, Date of Incident:
5. Time of Incident: c~ ,, c~% o,
6. Location of lncident (Be specific): O~ ir!r;\\
7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim. If a Ci~ employee was involved, give the
employee's name.)
8. ~hat were w~';~ conditions like? ~e~o~
9. Give name and address of any witnesses:_
~ O. Did poliae investigate? (If so, give n~mes of offiaers.)
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.)
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. Why do you claim the City of Dubuque is responsible? -~'~.
~/. reave you made any claim against anyone else for damages as a result of this incident?
(If ~s, give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that source,
and i~, in what amount?
Dated at D~_buque, Iowa this '50-~ day of
(Signature)
(Print Name)-
(Rev. 1/00 & 7/01)
Iowa Depar~zllent *fTra.spor~atlon ~ IOWaDepartment of Transportation
Office of Ddver Ser~ces
ParkFairMa~l. 100 Euclid Avenue INVESTIGATING OFFICER'S REPORT
P.O. Box 9204
Des MoMes, lowa 50306-9204 OF MOTOR VEHICLE ACCIDENT
corporate limits of (city~j;~J j~[_t~.~ E.
cityllmJtsshowgeneratvicinity miles 0 0 0 0 0 0 0 0 ofnearestc~ty
or Highway: J"~--~ ~-- .-.~ 'T~, [ At Imersection
or 0 0 0 0 0 0 0 0 and or
0 0 0 O0 0 0 0 o~
0 0 0 0
City State
,Middle)
Pos.
770 ~
Point Of
Most Damaged
Contri~3utffig CEcumstances, ~, ~,
23p
Lcx:at[°n°fF~rstHarmf~lEvent, L~J WeatflerCon~itions [013[ MajorContdbutingCirc~ms~-ance$:
~e~(~to~o) 1~I$1 L I
I I IL I J Po.~.~t
DAVE DeMOSS
Body Shop Manager
Date: 1/27/03 12:t7 PM
Estimate ID: 23
Estimate Version: 0
Preliminary
Profile ID: Mitcimll
DAN KRUSE PONTiAC-NISSAN, iNC.
B00 Century Drive
Dubuque, Iowa $2002
Bus. (563) 583-7345
Toll Free 1-800-373~.ARS
Pontiac, Nissan, BMW
600 CENTURY DRIVE DUBUQUE, IA 52002
(S63) ~3-7345
Fax: (563) 588-3874
Damage Assessed By: Dave DeMoes
BODYSHOP Dan Kruse Pontiac, ino
(563) 583-7345 ext. 228
Deductible: UNKNOWN
Insured: BROOK GASSMAN
Address: 606 SULLIVAN ST DUBUQUE, IA 52003'
Telephone: Home Phone: (563) 584-8987
Mitchell Service: 914778
Description: 2001 Nissan Sentra GXE
Body Style: 40 Sed Drive Train: 1,8L Inj 4 Cyl 4A
VIN: 3NICBSlDX1L459002
Option~: ~UM~LOY WHEELS, AIR CONDITIONING POWER STEERING, POWER WINDOWS
POWER DOOR EOCKS~ TILT STEERING WI.IEEL, CRUISE CONTROL, ELECTRIC DEFOGGER
AM-FM STEREO/CD PLAyER(sINGLE), AUTOMATIC TRANSMISSION
Line Entry Labor Une Item Part Type/
Item Number Type Operation Description Part Number
Dollar L;LbOr
Amount Units
I 400355 BDY REMOVE/REPLACE
2 400371 MCH ALIGN
3 401307 REF BLEND
4 401325 REF REFINISH
6 401329 BDY REMOVE/INSTALL
6 402162 BDY REMOVE/INSTALL
7 401335 SDY REMOVE/INSTALL
8 401426 BDY REMOVE/INSTALL
9 401534 BDY REMOVE/REPLACE
10 AUTO REF REFINISH
1t AUTO REF REFINISH
12 401560 SDY REMOVE/REPLACE
13 401825 BDY REPAIR
14 AUTO REF REFINISH
t5 AUTO REF ADD'L OPR
t6 933005 BDY ADD'L OPR
17 933006 FRM ADD'L OPR
18 933018 REF ADlYL OPR
19 AUTO ADD'L COST
20 AUTO ADD'L COST
WHEEL COVER
FOUR WHEEL
L FRT DOOR OUTSIDE
L FAT DOOR MOULDING
L FRT OTR BELT MLDG
L FRT DOOR MIRROR
L FRT DOOR ADHESIVE MOULDING
L FRT OTR DOOR HANDLE
L REAR DOOR SHELL
L REAR OOOR OUTSIDE
L REAR ADD FOR JAMBS & INSIDE
L REAR DOOR ADHESIVE MOULDING
L QUARTER OUTER PANEL
L QUARTER PANEL OUTSIDE
CLEAR COAT
RESTORE CORROSION PROTECTION
FRAME/RACK SET UP
MASK FOR OVERSPRAY
PAINTAMATERIALS
HAZARDOUS WASTE DISPOSAL
ORDER FROM DEALER
Existing
H2101-SM030
82871-47.0t4
Existing
45.15
1.0
C 0.8
C 0,5
t.0 # '
INC #
0.3 #
355.72 4.5
C
C 1.0
43.30 0,,1
6,0*#
C 1.7
t..5
5.00' 0,3'
t.5'
5.00 *
195.00 *
3.50 *
ESTIMATE RECALL NUMBER: 1/27/03 12:15:06 23
UitraMnte is a Trademark of Mitchefl International
Mitchell Data Veroion: JAN_03_A Copyright (C) 1994 - 2002 Mitchell Intemntional
UitraMnte Verelon: 4.8.012 All Rights Reserved
Page I of 2
Date: 1/27/03 12:17 PM
Estimate ID: 23
Estimate Version: 0
Preilmicary
Profile ID'. Mitcheil
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Cais
ill.
Add'l
Labor Sublet
Labor Subtntais Units Rate Amount Amount Totals Il. Par~ Replacement Summary Amount
Body 12.4 4~.00 $.00 0.00 563.00 T Taxable Parts 444.t7
Refinish 7.8 45.00 5.00 0.00 356.00 T Sales Tax ~ 6.000% 26.65
Frame 1.5 47.00 0.00 0.00 70.50 T
Mechanical 1.0 65.00 0.00 0.00 65.00 T Total Replacamest Parte Amount 470.82
Taxable Labor
Labor Tax
Labor Summary 22.7
Additional Costs
Non-Taxable
Total Additional Costs
1,117.77
Amount IV. Adjustmente Amount
198.~0 Customer Responsibility 0.00
t98.50 -
I. Total Labor: 1,ti?.77
II. Total Reptacoment Par~s: 470.82
gl. Total Add~ou;d Costs: 198,50
Gross Total: 1J87:09
IV. Total Adjustments: 0.00
Net Total: t,787.09
This is a ~reliminary estimate.
Additional changes to the estimate may be required for the actual repair.
THIS D~ REPOI~T IS BASED ON OUR INSPECTION AND DOES NOT COVER AN~
ADDITIONAL PARTS OR LABOR WHICH M~Y BE REQUIRED AFTER THE WORK H~S
BEEN OPENED UP. IF ADDITIONAL PARTS AND/OR LABOR ~ NEEDED THE
INSUP~NCE COMPANY WILL BE NOTIFIED.
WE FF~k0~a~ A THREE YF~R WOE.~I~I~NSHIP LIMITED ~e~D~D~NTY- SEE OUR W~ITTEN
~ FOR COMPLETE DETAILS. (EFFECTIVE 10-01-01)
WARNING: Accidental air bag deployment is possible. Personal injury may rssulL Avoid arsa nest ntesring wheel
and iostrament panel even if a~r bags have deployed. Dual*stage air bag modules may be present that could
contain au undepleyed stage. When disposing of a deployed dual-stage ;dr bag, always treat it es a "live" modula.
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM information.
ESTIMATE RECALL NUMBER: 1/27/03 12:16:06 23
UitmMnte is a Trademark of Mitcbetl Intarn;dioual
Mitch;dl Data Version: JAN_03_A Copyright (C) 1994 - 2002 Mitchell International
U~mMate Version: 4.8.012 AIl Rights Reserved
Page 2 cW 2