Claim by Jacob SchmitzCLAIM AGAINST THE CITY OF DUBUQUE, IOWA -~'
nstitutes our claim a ainst the Cit of Dubu ue, Iowa. You
This written report co y g Y q
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 West 13th St.,
Dubuque, IA 52001. It will then be referred to the appropriate department for
investigation and to the City Attorney's Office. 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: Jacob Schmitz
2. Address: 2267 Crown Point Road
3. Telephone Number ~~~ ~`~ ~ ~ ~ %'
4. Date of Incident: (~ ~ - ~ 3 _ ~
5. Time of Incident: ~ ~ G~ U ~ ~"~ _
6. Location of Incident (Be pecific):
7. Describe the 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.)
~~ F~~
Gc ~ r U v ~ /` /Y~ ~/ U~,`~ ~F .y c_ r /' v c~ r-~ Uhl L ~ ~ r
8. What were weather conditions like?
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9. Give name and address of any witnesses:
~~
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10. Did police investigate? (If so, give names of o/ff~licers.) / 4 q ~~ 7
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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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 dam O
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~~ cl ~ S ~ ~ ~ ~ ~ ~ S 5 ~- ~ S cc-~.~~~c ~ G~ c-d
13. What other damages o you claim, if a-}~/?
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.)
1 hat amount do you claim fro the City of Dubuque?
~ ~fc~S-o ~~~ .S ~
16. Why do you claim a C,i~6 of Dubuque is res onsibl ?
G' ~~ G /" /' r~ ~ c2 ~v/! Chia ~~'
It r C~ n. ~ Q ~~- " . ~ D u t/
17. Have you made any claim against anyone else for damages as a result of
this iry~ident? (If yes, give name and address.)
/ ~' ~
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18. If the answer to Question 17 is yes, have you received any payment from that
source d if so, in what amount?
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Dated this day of ~ ~ ~ ~ ~~ , 20~. ~- ~`, -o --
cc~ ~ ~ i 1
C' sv ~
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(Signat e rn ~
C vlif S c~-~~ ~ Z
(Print Name)
Date:
Estimate ID:
Estimate Version:
Preliminary
Profile ID:
811312009 01:27 PM
8763
0
Mitchell
Mike Finnin Ford
3600 Dodge Street, Dubuque, IA 52003
(563) 556-1010
Fax: (563) 690-1086
Tax ID: 14-1862673
Damage Assessed By: Rick Stumpf
Deductible: 0.00
Claim Number: 8763
Insured: JACOB SCHMITZ
Address: 2267 CROWN POINT RD., DUBUQUE, IA 52002
Telephone: Home Phone: (563) 542-8377
Mitchell Service: 912627
Description: 2003 Ford Explorer Limited
Body Style: 4D Ut Drive Train: 4.6L Inj 8 Cyl AWD
VIN: 1 FIIAZU85W53UA62610
Color: BLACK
Options: CRUISE CONTROL, LEATHER SEATS, AUTOMATIC TRANSMISSION, V8 ENGINE
POWER DRIVER SEAT
Line Entry Labor Line Item
Item Number Type Operation Description
1 200003 BDY OVERHAUL FRT BUMPER ASSY
2 204840 BDY REPAIR FRT BUMPER COVER
3 AUTO REF REFINISH FRT BUMPER COVER
4 203439 BDY REMOVEIREPLACE GRILLE
5 200064 BDY REPAIR GRILLE OPENING PANEL
6 AUTO REF REFINISH GRILLE OPENING PANEL
7 200072 BDY REMOVE/INSTALL R HEADLAMP ASSY
8 200073 BDY REMOVE/INSTALL L HEADLAMP ASSY
9 200115 BDY REMOVEIREPLACE HOOD PANEL
10 AUTO REF REFINISH HOOD OUTSIDE
11 AUTO REF REFINISH ADD FOR HOOD UNDERSIDE
12 203134 BDY REMOVElREPLACE HOOD DEFLECTOR
13 201554 BDY REPAIR R FENDER PANEL
14 AUTO REF REFINISH R FENDER OUTSIDE
15 201555 BDY REPAIR L FENDER PANEL
16 AUTO REF REFINISH L FENDER OUTSIDE
17 201574 BDY REMOVEANSTALL R FENDER WHEEL OPENING MLDG
18 201575 BDY REMOVE/INSTALL L FENDER WHEEL OPENING MLDG
19 203334 BDS * REMOVE/REPLACE WlSHIELD GLASS
20 200589 BDY REMOVE/REPLACE R COWL/DASH TOP PANEL
21 200590 BDY REMOVElREPLACE L COWUDASH TOP PANEL
22 200677 BDY REPAIR R DOOR OPENING FRAME
23 AUTO REF REFINISH R DOOR OPENING FRAME COMPLETE
24 200678 BDY REPAIR L DOOR OPENING FRAME
25 AUTO REF REFINISH L DOOR OPENING FRAME COMPLETE
26 203998 BDY REPAIR R FRT DOOR SHELL
27 AUTO REF REFINISH R FRT DOOR OUTSIDE
ESTIMATE RECALL N UMBER: 08/13/2009 13:27:52 8763
Mitchell Data Version: JUL_09_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International
UltraMate Version: 6.7.024 All Rights Reserved
Part Type/
Part Number Dollar
Amount Labor
Units
1.9
Existing 1.5*
C 2.3
3L2Z 8200 BA 136.85 0.2
Existing 1.5* #
C 2.0
0.4
0.4
1 L2Z 16612 AA 397.52 1.2 #
C 2.8
C 1.4
ORDER FROM DEALER 78.57 0.2
Existing 1.0*#
C 2.1
Existing 1.0* #
C 2.1
0.4
0.4
Sublet 325.00 0.0*#
6L2Z 78022A68 AAA 79.55 0.3 #
6L2Z 78022A69 AAA 74.48 0.3 #
Existing 1.5*
C 5.5
Existing 1.0*
C 5.5
Existing 1.0*#
C 2.0
Page 1 of 3
28 203999 BDY REPAIR L FRT DOOR SHELL
29 AUTO REF REFINISH L FRT DOOR OUTSIDE
30 203081 BDY REMOVE/INSTALL R FRT OTR BELT MOULDING
31 203082 BDY REMOVE/INSTALL L FRT OTR BELT MOULDING
32 200757 BDY REMOVE/INSTALL R FRT DOOR MIRROR
33 200758 BDY REMOVEIINSTALL L FRT DOOR MIRROR
34 200807 BDY REMOVE/INSTALL R FRT DOOR TRIM PANEL
35 200808 BDY REMOVE/INSTALL L FRT DOOR TRIM PANEL
36 203076 REF REFINISH L FRT OTR HANDLE
37 200845 BDY REMOVE/INSTALL R FRT OTR DOOR HANDLE
38 200846 BDY REMOVE/INSTALL L FRT OTR DOOR HANDLE
39 936014 ADD'L COST FLEX ADDITIVE
40 AUTO REF ADD'L OPR CLEAR COAT
41 933005 BDY ADD'L OPR RESTORE CORROSION PROTECTION
42 933018 REF ADD'L OPR MASK FOR OVERSPRAY
43 AUTO ADD'L COST PAINT/MATERIALS
44 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL
" -Judgment Item
# -Labor Note Applies
C -Included in Clear Coat Calc
Estimate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount
Body 17.8 55.00 20.00 0.00
Refinish 34.3 55.00 10.00 0.00
Taxable Labor
Labor Tax @ 7 .000
Labor Summary 52.1
III. Additional Costs
Taxable Costs
Sales Tax @ T.000%
Non-Taxable Costs
Total Additional Costs
Date: 8!1312009 01:27 PM
Estimate ID: 8763
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Existing 1.0* #
C 2.0
0.5 #
0.5 #
INC #
INC #
INC
INC
C 0.5
0.7 #
0.7 #
8.00
6.1 *
20.00 0.2*
10.00
1,200.50 *
5.00
Totals II. Part Replacement Summary
999.00 T Taxable Parts
1,896.50 T Sales Tax
2,895.50 Total Replacement Parts Amount
202.69
3,098.19
Amount IV. Adjustments
8.00 Insurance Deductible
0.56
Customer Responsibility
1,205.50
1,214.06
I. Total Labor:
II. Total Replacement Parts:
III. Total Additional Costs:
Gross Total:
IV. Total Adjustments:
Net Total:
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 08!13/2009 13:27:52 8763
Mitchell Data Version: JUL_09_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International
UltraMate Version: 6.7.024 All Rights Reserved
7.000% ~-76.44
1,168.41
0.00
3,098.19
1,168.41
1,214.06
5,480.66
0.00
5,480.66
Page 2 of 3
Date: 811312009 01:27 PM
Estimate ID: 8763
Estimate Version: 0
Preliminary
Profile ID: Mitchell
ESTIMATE RECALL NUMBER: 08113!2009 13:27:52 8763
Mitchell Data Version: JUL_09_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 3 of 3
UltraMate Version: 6.7.024 All Rights Reserved