Claim by Joe Frederick~-~~-~ ~
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA~"`~ ~'
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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: ~o~ ~ireC~N~ i' C
2. Address:
3. Telephone Number
5~3 - S~{3 ~ pS~~
4. Date of Incident: 9 - ~ ~/ ` ~
5. Time of Incident: l~•~ ~ _ ~' U ~ P ~'
6. Locatio~f IncideInt (Be specific): 1 J/ 1 /
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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.) ~ ~ , ~ ~, ii.~ ~~
That were weat er conditions like?
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10. Qi~ police investigate? (If so, give names of officers.)
9. Give name and address of any witnesses:
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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~f amage.)
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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
arr~o~nt paid.)
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15. What amou~It~ do you claim from the City of Dubu ue?,(~
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16. Why do you cl im the City of }~ubuque is responsible? ,
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17.
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Have you made any claim against anyone else for damages as a result of ~' ~ S~~'rc~ ~-
ir~cident? (If yes, give name and address.)
18. If the answer to Question 17 is yes, have you received any payment from that
source, end if so, in what amount?
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Dated this ~ day of Se,~~ ~-~' , 20~.
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09/15/2009 at 05:20 PM
30799
Job Number:
BRIMEYER AUTO BODY
License #:30799 Federal ID #:421436480
10709 COLLISION DR.
DUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
PRELIMINARY ESTIMATE
Written By: BOB COOK
Adjuster:
Insured: JOE FREDERICK Claim #
Owner: JOE FREDERICK Policy #
Address: 482 PRIMROSE Deductible:
DUBUQUE, IA 52001 Date of Losa:
Evening: (563)552-1442
Type of Losa:
Point of impact:
Inspect
Location:
Insurance
Company:
Days to Repair
2007 CHEV K 1500 4X4 EXT LS NEW 8-5.3L-FI 4D LONG BLUE Int:
VIN: 2GCEK19J871648766 Lic: Prod Date: Odomete r:
Air Conditi oning Tilt Wheel Intermittent Wipers
Message Cen ter Dual Mirrors Overhead Console
Clear Coat Paint Power Steering Power Brakes
AM Radio FM Radio Stereo
Search/Seek Anti-Lock Brakes (4) Driver Air Bag
Passenger A ir Bag Communications System Rear Step Bumper
Automatic T ransmission 4 Wheel Drive Overdrive
Styled Stee l wheels
N0. ------------------ -----
---- --------------
OP. DESCRIPTION QTY EXT. PRICE LABOR
----------- -- ___
---
PAINT
1 -- -----
---- ----- -----------
FENDER
2* Rpr RT Fender Chevrolet
3 0.5
Add for Clear Coat 2.0
4#
R&I MUD FLAP 0.8
5 ~ 2
FRONT DOOR
6* Rpr RT Door shell
7 0.5
Overlap Major Adj. Panel 2.4
8
Add for Clear Coat -0.4
9
R&I RT Belt w'strip 0.4
10 0.3
Repl RT Nameplate "SILVERADO" 1 29.41 0.3
11 Repl RT Emblem 1 7.70 0.2
12* R&I RT Body side mldg Chevrolet 0.3
ext, crew cab
13 R&I RT Mirror assy code:DF2 w/o 0.4
heated black
14# RETAPE MLDG 1
15 0.3
R&I RT R&I trim panel
16 0.4
R&I RT Handle, outside black
w/o
,
0 4
keyless entry
17# CAR COVER 1 5.00
18 OTHER CHARGES
19# E.P.C. 1 5.00
------- ----------
-------------------- ---- ----
Subtotals =_> 47.11 3.8 - -----
5.2
Parts
42.11
Body Labor 3.8 hrs @ $ 55.00/hr 209.00
Paint Labor 5.2 hrs @ $ 55.00/hr 286.00
Paint Supplies 5.2 hrs @ $ 35.00/hr 182.00
Other Charges
--- ------------------ 5.00
-- ---- ----------- --
SUBTOTAL $ --- ----
724.11
Sales Tax $ 542.11 @ 7.0000 8
-------------------- 37.95
---- ----------------
GRAND TOTAL $ ----- --
762.06
ADJUSTMENTS:
Deductible 0.00
1