Claim by Karin Campbell~` ~ it ~~>'
.,
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA~~~~~ f~3'D.~~ =tee
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 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: Karin Campbell
2. Address: 2358 Graham Circle
3. Telephone Number ~ ~ ~ -- `~13 ~ y~ l ~ ~~~~~ i MQ. S`~b - ~ ~~?(~ C-X~. I a
4. Date of Incident: ~ 7CA 13
5. Time of Incident: ~: ~b
6. Location of Incident (Be specific): 5th Street Parking Ramp
t 1r~ St ~Q ~ ~T (` ~.i pG Q.~tY117
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.) _
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 officers.)
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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.)
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13. What other damages do you claim, if any?
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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.)
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15. What amount do you claim from the city of Dubuque?
~~
16. Whyldo you claim,~tnhe1/C~ity orfy~Druyb``uque is•r~esponsi,}b~l~e?/- 'L,~1 ) r' M f~
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17. Have you made any claim against anyone else for damages as a result of
this incident? (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, and if so, in what amount? '
Dated this r St day of ~~ . , 20
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(Signature) ~j ~f . ~ ~ ~ w?t~
~ ,~~~ ~` ~~S 6
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(Print Name) ~~i'j~.;;.
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Date: 9/ 112009 04:20 PM
Estimate ID: E9622
Estimate Version: 0
Preliminary
Profile ID: Mitchell
KRUSE-WARTHAN Nissan, Pontiac, BMW
600 Century Drive, Dubuque, IA 52002
Email: bthill@dubuqueautoplaza.com
Tax ID: 420655341
Damage Assessed By: BILL THILL
Deductible: 0.00
Claim Number: NA
Insured: KARIN CAMBELL
Address: 2358 GRHAM CIRCLE, DUBUQUE, IA 52002
Telephone: Home Phone: (563) 513-4016
Mitchell Service: 912779
Description: 2006 Nissan Altima
Body Style: 4D Sed Drive Train: 2.SL Inj 4 Cyl 5M FWD
VIN: 1N4AL11D86C172566
Options: VEHICLE ANTI-THEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER LOCK
POWER WINDOW, POWER BRAKE, REAR WINDOW DEFOGGER, TILT STEERING COLUMN
REMOTE FUELDOOR RELEASE, MANUAL REMOTE ADJUSTABLE EXTERIOR MIRROR, FRONT AIR DAM
TINTED GLASS, FIRST ROW BUCKET SEAT, SECOND ROW BENCH SEAT
SECOND ROW FOLDING SEAT, CLOTH SEAT, VARIABLE ASSISTED STEERING, TACHOMETER
PASSENGER AIRBAG CUTOFF SWITCH/SENSOR, REMOTE DECKLID OR TAILGATE RELEASE
Line
Item Entry Labor
Number Type
Operation Line Item
Description Part Type/
Part Number Dollar
Amount Labor
Units
1 202328 BDY REPAIR Roof Panel Existing Y
S~
2 AUTO REF REFINISH Roof Panel .
3
202332
BDY
REMOVE/INSTALL
R Roof Moulding
Existing C 2 7
0
4
202333
BDY
REMOVE/INSTALL
L Roof Moulding
Existing .3 r
0
5
900500
BDY *
REPAIR
LEFT ROOF RAIL
Existing .3 r
4
•
6 900500 REF " REFINISH/REPAIR LEFT ROOF RAIL Existing ,0
2
'
7 203876 BDY REMOVE/REPLACE L Frt Roof Drip Rail Moulding 76813-8J000 157
87 .5
0
3
8 AUTO REF ADD'L OPR Clear Coat . .
9
AUTO
ADD'L COST
PAINT/MATERIALS 1.1'
10
AUTO
ADD'L COST
Hazardous Waste Disposal 201.60
3.50
" -Judgment Item
C -Included in Clear Coat Calc
r - CEG R&R Time Used For This Labor Operation
ESTIMATE RECALL NUMBER: 09/01/2009 16:20:59 E9622
Mitchell Data Version: OEM: JUL_09_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 1 of 2
UltraMate Version: 7.0.010 All Rights Reserved
Date: 9/ 1/2009 04:20 PM
Estimate ID: E9622
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Estimate Totals
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Body 5.4 52.00
Refinish 6
3 0.00 0.00 280.80 T Taxable Parts 157
87
.
52.00 0.00 0.00 327.60 T Sales Tax @ 7.000% .
11.05
Taxable Labor 608.40 Total Replacement Parts Amount 168
92
Labor Tax @ 7.000 % 42.59 .
Labor Summary 11.7 650.99
III. Additional Costs Amount IV. Adjustments
Non-Taxable Costs
205.10
Insurance Deductible Amount
0.00
Total Additional Costs 205.10 Customer Res
onsibili
p
ty 0.00
Paint Material Method: Rates = 32.00
I. Total Labor: 650.99
II. Total Replacement Parts: 168.92
III. Total Additional Costs: 205.10
Gross Total: 1,025.01
IV. Tctal Adjustments:
Net Total:
This is a preliminary estimate
Additional changes to the estimate may be required for the actual repair
THIS DAMAGE REPORT IS BASED ON OUR INSPECTION AND DOES NOT
COVER ANY ADDIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER
THE WORK HAS BEEN OPENED UP. THE INSURANCE COMPANY WILL BE NOTIFIED.
WE GUARANTEE OUR COLLISION REPAIR WORKMANSHIP FOR AS LONG AS YOU OWN
YOUR VEHICLE.
ACCIDENTS ARE A PAIN BUT WE MAKE THE REPAIR A PLEASURE!!!
ESTIMATE RECALL NUMBER: 09/01!2009 16:20:59 E9622
Mitchell Data Version: OEM: JUL_09_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International
UltraMate Version: 7.0.010 All Rights Reserved
0.00
1,025.01
Page 2 of 2
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