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Claim by Richard L. Hanson CLAIM AGAINST THE CITY OF DUBUQUE, IOWA 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: /~ i~ ~ ~ ~ ~~~j ~-t~iT ~~ 7 2. Address: ~ _~i ~ ~ y2 ~~1 ~/-Z 4 ` /-~J ~ -~~ b ~ s ~~. ,~ ~4 s~ r 3. Telephone Number___5 ra.3 5-~5 ~ - ~ 3 ~ ~r C'c,~l ~ ~~-~ ~~/~ 74/! ~ 4. Date of Incident: _ ~~ ~ c, a2.. 2, ,,2 cSO l 5. Time of Incident: ~3 ,~ ~~ p~ 6. Location o~ Inci~ent (Be specific): { ~-~©~ 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.) , ,~ ~,~ .- .ri is q!- r L ~ ~~ ~~C ti ~ -4~,u-l~-R KJ~S Ca: 8. What were weather conditi bhp, '~/'O11~`}'~' cSlG L°., cS 7' '/'` ~ C'1~rn '~ V"Q s.~ F6 B~~y-~c~ s like? ~'~ ~- ~ ~- c~ ~~ ~ L 9. Give name and address of any ~. 10. Did police investigate? (If so, give names of officers.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). !1J ~ 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 damag~~~ 1~~~~,~ ~ 1 _`~ ~ ~. ~ ~~y~ 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.) ,~) p 15. What amount do you claim from the City of Dubuque? 16. Why do you claim the ity ~f Dubuque is responsible? ~ ~ ~ ~'Z, 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, ive 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 '~.J -~' (-. __` w / r ' J i~ (Signature) ~ ~' `j' '~ (Print Name) 12/22/2009 at 05:35 PM ~ r 30799 BRIMEYER AUTO BODY License #:30799 Federal ID #:421438480 10709 COLLIS]:ON DR. DUBUQUE, IA 52001 (563)583-4456 Fax: 563)583-1838 PRELIMINARY ESTIMATE Written By: BOB COOK Adjuster: Insured: RICHARD HANSON Claim # Owner: RICHARD HANSON Policy # Address: 2326 1/2 CENTRAL AVE Deductible: DUBUQUE, IA 52001 Date of Losa: Day: Type of Loss: Evening: Point of Impact: Inspect Location: Job Number: Insurance Company: Days to Repair 2002 BUIC LESABRE CUSTOM 6-3.BL-FZ 4D SED Ir.t: VIN: 1G4HP54K3242 17377 Lic: Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Auto Level Keyless Entry Body Side Moldings Dual Mirrors Overhead Console Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Mirrors Power Trunk/Gate Release AM Radio FM Radio Stereo Cassette Search/Seek Anti-Lock Brakes (4) Driver Air Bag Passenger Air Brig Front Side Impact Air Ba g 4 Wheel Disc Brakes Cloth Seats Automatic Transmi ssion Overdrive ------ ------ - Full Wheel Covers - - N0. OP. -------- ------ ----- -------------------------- DESCRIPTION ------ --------- -- QTY --------- -- ----- EXT. PRICE LABOR ------ PAINT -- 1 --- ----------- FRONT BUMPER --- --------- ------- ------ - - 2 R&I R&i bumper cover 1.2 3* Rpr Bumper cover Custom 2.5 2.8 4 Add for Clear Coat 1.1 5 FRONT LAMPS 6** Repl A/M LT Headlamp assy w/o 1 213.00 0.3 cornering lamp 7 Aim headlamps 0.5 8 FENDER 9* Rpr LT Fender 2.5 1.8 10 Add for Clear Coat 0.7 11# CAR COVER 1 5.00 12 OTHER CHARGES 13# E.P.C. 1 5.00 Subtotals -_> ----- 223.00 7.0 -- --- 6.4 -- Parts 218. 00 Body Labor 7 .0 hrs @ $ 55.00/hr 385. 00 Paint Labor 6 .4 hrs @ $ 55.00/hr 352. 00 Paint Supplies 6 .4 hrs @ $ 35.00/hr 224. 00 Other Charges ---- ----------- 5. 00 ----- SUBTOTAL --- ------------ - ---- ---- - $ 1184. -- 00 Sales Tax $ 960.00 @ 7.0000 ~ 67. 20 GRAND TOTAL $ 1251.20 ADJUSTMENTS: Deductible 0 00 ---- ------- --------- ------------ CUSTOMER PAY ~ $ 0.00 INSURANCE PAY $ 1251.20 1