Claim by John & Jim Bechen~ ~ $, ~°
CI'A' IJ IJ I7 ,
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 13t" 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.
,A
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: John Bechen, Jim Bechen
2. Address: 7745 Hidden Valley 8649 Harvest LN
3. Telephone Numbers ~~~ ~:~`® '~ "~ ~ .~~~' 'j `
_,,' , ~r mod" `~` ~ ~- ~ ~ ~ ~ ;~
4. Date of Incident: ,~ (~ C~ ~
5. Time of Incident: ~'
6. Location of Incident (Be specific): Down in the Landfill Trash unloading area
-.
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? ~.i °°
. / - ra - e°r;
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9. Give name and address of any witnesses:
«~-~-o
10. Did police investigate? (If so, give names of officers.)
11 Was anyone injured? (If so, give names, addresses, and extent of injuries)._
~~~~
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 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,E Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against anyone else for damages as a result of
this incident? (If yes, give 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 this ,~~~, day of ,~~,~r,~,~..~,~~~~- , 20 ~ r~ ~?
f - ~ . ~ ~ ~;
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(Signature) ~ ~ ~ ~- "-`~ ~ i
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--~' ,.
4 ~-~
(Print Name) `~~~ ~~
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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 damaae.l
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4~1 (/y
11/06/2009 at 10:32 AM
24443
AE - DUELTQLTE
Federal ID #:420782245
DBA: ANDERSON-WEBER INC
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563)556-0696 Fax: (563)556-1899
PRELIMINARY ESTIMATE
Written By: RICK KELLY
Adjuster:
Insured: JIM BECHEN Claim #
Owner: JIM BECHEN Policy
Address: 8659 HARVEST LANE Deductible:
DUBUQUE, IA 52003 Date of Loss:
Evening: (563)557-4460 Type of Loss:
Point of Impact: 2
IrispeCt
LOCatlon:
Job Number:
Right Front Pil
Insurance CUSTOMER PAY
Company: Days to Rep air
1997 DODG BR1500 4X4 8-5.9L-FI 2D LONG BLUE Int: GRAY
VIN: 1B7HF16Z7V6581155 Lic: NA IA Prod Date: 02/1997 Odometer: 71516
Intermittent Wipers Dual Mirrors Clear Co at Paint
Power Steering Power Brakes AM Radio
FM Radio Stereo Cassette
Anti-Lock Brakes (2) Driver Air Bag 5 Speed Transmission
Overdrive
------
-----
---------
----------
-------
----------
N0. ------
OP. --------------------------
DESCRIPTION
-------------------------- QTY EXT. PRICE
-------------- LABOR PAINT
-----------------
----------
1 ------ ------
FRONT BUMPER
2 R&I R&I bumper assy 0 0.00 0.6 0.0
3 FRONT LAMPS
4 ~ R&I RT Headlamp assy 0 0.00 0.5 0.0
5 FENDER
6* Rpr RT Fender assy 0 0.00 1.0 2.0
7 Add for Clear Coat 0 0.00 0.0 0.8
8 R&I RT Body side mldg 0 0.00 0.2 0.0
9 FRONT DOOR
10* Rpr RT Door shell 2 door 0 0.00 2.0 2.8
11 Overlap Major Adj. Panel 0 0.00 0.0 -0.4
12 Add for Clear Coat 0 0.00 0.0 0.5
13# Refn BLEND PAINT WITHIN DOOR 0 0.00 0.0 -0.2
14* R&I RT Nameplate "RAM 2500" chrome 0 0.00 0.2 0.0
15* R&I RT Body side mldg 0 0.00 0.3 0.0
16* R&I RT Nameplate "V6 MAGNUM" 0 0.00 0.2 0.0
17 R&I RT Belt w'strip inner 0 0.00 0.3 0.0
1
11/06/2009 at 10:32 AM
24443
Job Number:
P LIMINARY E$TIi~TE
1997 DODG BR1500 4X4 8-5.9L-FI 2D LONG BLUE Int:GRAY
---------
NO. -------
OP. -------------------------------
DESCRIPTION ---------------
QTY EXT. PRICE ---------
LABOR
------- --------
PAINT
--------
---------
18 -------
R&I -------------------------------
RT Mirror 9x6 assembly ------
0 -------
0.00 -- --
0.3 0.0
manual, black
19 R&I RT Handle, outside 0 0.00 0.3 0.0
20 R&I RT R&I trim panel 0 0.00 0.5 0.0
21 PICK UP BOX
22* Rpr RT Side panel single rear 0 0.00 12.0 3.2
wheel, 8 ft bed from 3-95 US,
fr 4-95 Mex, 8 ft bed
23 Overlap Major Non-Adj. Panel 0 0.00 0.0 -0.2
24 Add for Clear Coat 0 0.00 0.0 0.6
25# Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0
26# Subl BAG / COVER CAR 1 10.00 0.0 0.0
27# Subl CORRISON PROTECTION 1
------ 10.00
------- T
-- 0.0
--------- 0.0
--------
--------- ------- -------------------------------
Subtotals =_> 24.00 18.4 9.1
Parts 10.00
Body Labor 18.4 hrs @ $ 55.00/hr 1012.00
Paint Labor 9.1 hrs @ $ 55.00/hr 500.50
Paint Supplies 9.1 hrs @ $ 35.00/hr 318.50
Sublet/Misc.
------ 14.00
--------
--------------------
SUBTOTAL ------ ------- -- ---
$ 1855.00
Sales Tax $ 1536.50 @ 7.OOOOo 107.56
GRAND TOTAL $ 1962.56
ADJUSTMENTS:
Deductible 0.00
----------------------------------------------------
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 1962.56
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PARTS SUBJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
2
11/06/2009 at 10:32 AM
24443
Job Number:
P L2~lIL~TY ES~'I ~'E
1997 DODG BR1500 4X4 8-5.9L-FI 2D LONG BLUE Int:GRAY
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived
from the Guide DR3TA94, CCC Data Date 11/02/2009, and the parts selected are OEM-parts
manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at
OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts
that may be provided by or through alternate sources other than the OEM vehicle dealerships.
OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT
OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle
dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor
information provided by MOTOR may have been modified or may have come from an alternate data
source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original
Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts
which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy
Parts, RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described
as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass
Specifications. Labor operation times listed on the line with the NAGS information are MOTOR
suggested labor operation times. NAGS labor operation times are not included. Pound sign (#)
items indicate manual entries. Some 2010 vehicles contain minor changes from the previous year.
For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and
parts data from the previous year may be used. The Pathways estimator has a complete list of
applicable vehicles. Parts numbers and prices should be confirmed with the local dealership.
CCC Pathways - A product of CCC Information Services Inc.
3
11/06/2009 at 10:56 AM
94524
TLTRPIN DODGE OE' DUETJQLTE, LLC
90 KENNEDY RD
DUBUQUE, IA 52001
(563)583-5781 Fax: (563)556-6928
PRELIMINARY ESTIMATE
Written By: TERRY FORTMANN
Adjuster:
Insured: JIM BECHEN
Owner: JIM BECHEN
Address: 8659 HARVEST LN
DUBUQUE, IA 52003
Other: (563)599-5600
Inspect
Location:
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Job Number:
Insurance
Company: Days to Rep air
1997 DODG BR1500 4X4 8-5.9L-FI 2D LONG Int:
VIN: 1B7HF16Z7VJ581155 Lic: Prod Dat e: Odometer:
Intermittent Wipers Dual Mirrors Clear Co at Paint
Power Steering Power Brakes AM Radio
FM Radio Stereo Cassette
Anti-Lock Brakes (2) Driver Air Bag 5 Speed Transmission
Overdrive
NO.
-- OP.
- DESCRIPTION
------------ QTY EXT. PRICE LABOR PAINT
--------
1 ----- --------------------
FENDER --- ----------- --------- --------
2* Rpr RT Fender assy 0.5 2.0
3 Add for Clear Coat 0.8
4 FRONT DOOR
5* Rpr RT Door shell 2 door 1.0 2.8
6 Overlap Major Adj. Panel -0.4
7 Add for Clear Coat 0.5
8 Repl LT Nameplate "V8 MAGNUM" 1 40.30 0.2
9* Repl RT Nameplate "RAM 1500" chrome 1 65.00 0.2
10 R&I RT Belt w'strip outer 0.3
11 PICK UP BOX
12* Rpr RT Side panel single rear 6.5 2.7
wheel, 6.5 ft bed from 3-95
US, fr 4-10-95 Mex built
13 Overlap Major Non-Adj. Panel -0.2
14 Add for Clear Coat 0.5
15 CAB
16# HAZARDOUS WASTE 1 5.00 T
17* Rpr Cab CORNER 0.5 1.5
18# MOLDING KIT 1 40.00 1.0
1
11/06/2009 at 10:56 AM
94524
Job Number:
PRELIMINARY ESTIMATE
1997 DODG BR1500 4X4 8-5.9L-FI 2D LONG Int:
----------------------------------------------
N0. OP. DESCRIPTION ----------------
QTY EXT. PRICE ---------
LABOR --------
PAINT
----------------------------------------------
19# CAR COVER -------
1 -------
5.00 --
T --------- --------
----------------------------------------------
Subtotals =_> ------- -------
155.30 -- ---------
10.2 --------
10.2
Parts 145.30
Body Labor 10.2 hrs @ $ 55.00/hr 561.00
Paint Labor 10.2 hrs @ $ 55.00/hr 561.00
Paint Supplies 10.2 hrs @ $ 35.00/hr 357.00
Sublet/Misc. 10.00
-------------------
SUBTOTAL ------- ------- -- ---------
$ --------
1634.30
Sales Tax $ 1634.30 @ 7.0000% 114°40
GRAND TOTAL $ 1748.70
ADJUSTMENTS:
Deductible 0.00
----------------------------------------------------
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 1748.70
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide DR3TA94, CCC Data Date 10/01/2009, and the parts selected are OEM-parts manufactured by
the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships.
OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or
through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may
reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may
include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or
Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have
been modified or may have come from an alternate data source. Tilde sign (~) items indicate MOTOR
Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described
as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used
parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as
Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are
provided by National Auto Glass Specifications. Labor operation times listed on the line with the
NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not
included. Pound sign (#) items indicate manual entries. Some 2010 vehicles contain minor changes
from the previous year. For those vehicles, prior to receiving updated data from the vehicle
manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has
a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the
local dealership.
CCC Pathways - A product of CCC Information Services Inc.
2
I L
~ ~ T'ERRA' FORTIviAAtIV
I I ~"~ Body Shop Manager
-'® Of Dubuque 90 Ken~rvaorRn • DueuQu~ IA 52002
tfortman@mrpin-do dge. com
~ www.hirpin-dodge.com
(563) 5~3-971
=_---==~`1 ~ r~_= - _ (~00) 747-4221
~ _ - - --
- .._ _. _ _ ,~ - _, ~ ~ 1UURPdEY
~~
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