Claim by Ron and Ann BurdsI~~`;~'
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 13~' 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: ~cm ~ /~r~n C3vrdS
2. Address: 131t N Granc9~tct,:3 ~u6v~vv i~ -~~~i
3. Telephone Number: Sfo3 `; SL ~ ~ 3 `'i /inn 1.. c.~ 5 ~ ~ ' S 8 `t- FSCU'7~
4. Date of Incident: ~ Z~i'7~U`i
5. Time of Incident: ~~ ~ S~- ISM
6. Location of Incident (Be specific): Z9 i sand off - ~ ~b vc; w~, i A
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.)
C ;-{-y ~ .wir~l~~e~ C a~~.w~szs ~~i+i-r 1 ~os-~ ~ ~~-~~ ~~
~~ n c~ c~~ I;s ~ o ~ b~~-e-rl 1~_ -Irvc~ . My oar l~s_c~ ~-~-) a ~fil ~~ Qcie~ av~
8. What were weather conditions like? Caid , ~r~, ,~' 1 l_ ' ~ '~`~ rG~ tPCI/~~CI~ '
9. Give name and address of any witnesses: ~c{.W~.S w~ ~~1 - l(O ~~ d~ ~ W ~ ~~d
r 1
10. Did police investigate? (If so, give names of officers.)
vas ~~~ ~1~~'eS
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.)
r<=~ttC./~StyG c~cc.rnc~c„~, fiC~ body U~ G~L~94 ~'i~ ~~c~.vQ-
>_~ss er1 Pr-~ many t!5ot`~ Gc~C%~'. 'I'r~x.~0.to~r1 .
r' :f-s
13. What other damages do you claim, if any? ~~ PAC ~n~ c>~
~ e QeaC~r w~ ~A~~ ~ ca a~~ as%- ~n~ ~o~,n ~~'t ar, ~ -~->r-~ri~C ~'c c^
~~ r~ t-~ -}~tn~c~{ ~4-,` MCA
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name a
address of insurance company and amount paid.)
15. What amount do you claim from the City of Dubuque?
:~i Qp1'~ maLc. ~~.-- itcbe~un~ ~~
S4~1~ . 7 FS~
CY.~r. Pt~s ~'e-ntr~.Q ~e~~~ i~ ~cl.cd
16. Why do you claim the City of Dubuque is responsible? ~~clr~- +- dc~.mctc,~A ~.%vtz--
C~c3' ~ ~ f t p~ C ~ t Y ~rY~ fo ~~ac.~- ~ cl.,~ i V ~. o~ q Ccn1~r~. ~~ rc~c_l~~
i,J ho [air. Cont-ro~ ~;{ 01 Lh ~ c1t.t . h ~ ~ i nc~ ~ (acc~J'L.jr_C~ Ccw
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
address.)
No
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 i-I day of ~~M~ , 20 0~.
(Signature)
~, ~~5 A>1~, B~.~ds
(Print Name)
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Date:
Estimate ID:
Estimate Version:
Preliminary
Profile ID:
BIRD CHEVROLET
3255 UNIVERSITY AVE, DTIBUQi7E, IA 52001
(563) 583-9121
Fax= (563) 556-4482
Tax ID: 42-0400210
Damage Assessed By: john klotz
Deductible: 0.00
Claim Number= 8070
Insured: AELX BURDS
Address: 1311 N GRANDVIEW, DUBUQUE, IA 52001
Telephone: Home Phone: (563) 451-7929
Mitchell Senrice: 916492
Description: 2002 Chevrolet S10 LS
12/17/2009 01:19 PM
8070
0
Mitchell
Body Style= 3D PkupRCb 6' Bed 122" WB Drive Train- 22L Inj 4 Cy12WD
VIN: 1 GC CS 195728164068
OEM/ALT: O Search Code: None
Options VEHICLE ANTITHEFT, PASSENGER AIRBAG, DRIVER SIDE AIRBAG, POWER STEERING
MANUAL AIR CONDITION, CRUISE CONTROL, TILT STEERING COLUMN, ANTI-LOCK BRAKE SYS.
ALUM/ALLOY WHEELS, LEATHER STEERING WHEEL, CD PLAYER, PRIVACY GLASS
FRONT AIR DAM, CLOTH SEAT, TACHOMETER, AUTOMATIC HEADLIGHTS
DAYTIME RUNNING LIGHTS
Line
Item Entry Labor
Number Type
Operation Line Item
Description Part Type/
Part Number Dollar
Amount Labor
Unite
1 700257 BDY REMOVE/REPLACE Replace Pickup Bed Assy Qual Recycled Part 1,500.00 * 2.5
2 AUTO REF REFINISH Pickup Bed Components C 8.5 #
3 Line Markup %25.00 375.00
4 700259 BDY REMOVE/REPLACE R Rear Combination Lamp Qual Recycled Part INC 0.3
5 700260 BDY REMOVE/REPLACE L Rear Combination Lamp Qual Recycled Part INC 0.3
6 *** END OF ATG SECTION ***
7 AUTO BDY OVERHAUL Frt Bumper Aasy 1.6 #
8 600106 BDY REMOVE/REPLACE Frt Bumper Face Bar 15094048 GM PART 261.92 INC
9 600138 BDY REMOVE/R.EPLACE Frt Bumper Impact Strip 15716712 GM PART 36.31 INC
10 60014.5 BDY REMOVF,/RF,PLACF, Frt Bumper Filler To Bumper 15015660 GM PART 43.31 TNC #
11 632145 BDY REMOVE/REPLACE Frt Bumper Air Deflector 88967923 GM PART 73.50 INC #
12 AUTO REF REFINISH Frt Air Deflector C 1.6
13 600175 BDY REMOVE/R.EPLACE L Frt Bumper Brace 15716713 GM PART 26.31 INC #
14 632154 BDY REMOVE/REPLACE Grille 19180339 GM PART 179.55 0.2
15 AUTO REF REFINISH Grille C 1.0
16 600155 BDY REMOVE/REPLACE Grille Moulding 12470331 GM PART 94.95 INC #
17 600405 BDY REMOVE/R.EPLACE Grille Emblem 15634687 GM PART 19.83 INC #
18 626750 8DY REMOVE/RF,PT,ACF, Tailgate Shell 12389420 GM PART 360.56 1.3 #
19 900500 BDY * REPAIR LKQ CLEAN UP E>vating 3.0*
20 AUTO BDY OVERHAUL Rear Bumper Asay 0.4
21 602054 BDY REMOVE/REPLACE Rear Bumper Face Bar ** QUAL REPL PART 390.00 * INC
22 COMPLE_4TE HIT
23 AUTO REF ADDZ OPR Clear Coat 3.0
24 AUTO ADD'L COST Paint/Materials 493.50
25 AUTO ADD'T, COST Hazardous Waste Disposal 6.00 *
ESTIMATE RECALL NUMBER= 12/17/2009 13:19:02 8070
Mitchell Data Version: OEM: NOV_09_V U1traMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 1 of 2
U1traMate Vereion: 7.0.014 Al] Rights Reserved
Date: 12/17/2009 01:19 PM
Estimate ID: 8070
Estimate Version: 0
Praliminarv
Profile ID: Mitchell
* - Judl?ment Item
# -Labor Note Applies
G -Included in Clear Coat Calc
Estimate Totals
Add'1
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount
Tandy 9.6 55.00 0.00 0.00 528.00 T Taxable Parts 2.98624
Refinish 14.1 55.00 0.00 0.00 775.50 T Parts Adjustments 375.00
Sales Tax @ 7.000% 235.29
Taxable Labor 1,303.50
Labor Tax dal 7.000 °~6 91.2.5 Total Replacement Parts Amount 3;596.53
Labor Summary 23.7 1,394.75
III. Additional Costa Amount IV. Adjustments Amount
Non-Taxable Costs 499.50 Insurance Deductible 0.00
Total Additional Costs 499.50 Customer Responsibility 0.00
Paint Material Method: Rates
Init Rate = 35.(1(1 , Init Max Hours =99.9, Addl Rate = 0.(1(1
I. Total Labor: 1,394.75
II. Total Replacement Parts: 3,596.53
III. Total Additional Coats: 499.50
rmss Total: 5,490,78
IV. Total Adjustments: 0.00
Net Total: 5,490.78
THIS ESTII+JPiTE HA3 BEEN PREPARED BASED ON THE USE OF AFTERMARF~T CRASH
PARTS 3UPPI,IED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR
VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE
PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THESE PARTS RATHER THAN
THE MANUFACTURER OF YOUR VEHICLE.
This is a prel;m;narv estimate.
Additional changes to the estimate may be required for the actual repair.
ESTIMATE RECALL NUMBER: 12/17/2009 13:19:02 8070
Mitchell Data Version: OEM: NOV 09 V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International Page 2 of 2
IJ1traMate Version: 7.0.014 All Rights Reserved
Dec. 23. 2009_r 2;08P
.No. 5922-P. 2
DlNafe Name -la:l First Middle SUlfix Hortielt:etl Ynone
MEYER COURTNEY MARIE 69J 642805 x
Addreae Clb Elflle Zb
9470AdAIRST DUBU UE IA 52001
Dale of BIRh Drlvor': Llun:a Number Cilalion Charge Code 1 Cilalion charge 1
09f7~11983 120ACS33~
Gondar Stele Glsea Endoraemenlo Reslricllana Cllallon Charge Goda Z Cilorlon Charge 2
Female IA C NONE NONE cn
ll
Alcohol Teet
Dlug Teel e
on cnar0e code s Ctlallon CnerOe 3
ONerr7 Te=l Rasulls: .Olven7 Tea Ra:ulls: Citnlbn Charge Code 4 Cilalion Charpa d
1 • None 1 -None
U Saaling Poshlon0l Injury Slatua 6 lJuupanl Proteclion2 Airbag Deployment S hGbap 6v/IchSlslue 9 F,jeGlon 1 FJerAlon Peln 1 Trappsd 7
N
I TranepoRed lo: 7renapo ad y,
. T own ~
a Name. LaaL COU MARI suf(hC OLVnarCampany Neme '
R RTNEY E
003 Adtlreas
1470ADA[R ST Cip~
DU9000S 81fl1e
IA ztP
62001
Insurance Cw Nams Insurance PolicyW Licenee Plafe B 8lela Year
pROGRE6SIVECASUALTY 30917599-0 921WRP IA 2070
VIN No. Year Make Model 9tyte Tow IF approrimale Cosl lc
iFALPe534T1(1@4T@o 1888 FOrd•FORD CNT 4b YE9 RepeirorReplace
IniGalTravet VeNcle Ceed PolMo( MoatDamegad Exlanlol Undenldar Plfvalo7
^
Dfracuon 3 Acnon 01 Llmll 26 InillalYmpacl 08 Arne OD Remage 6 Override 1 52,50D.00
Totol 7ratflo Vehkle Cargo Body Vehida DlNet Vision Conl(ihuling CkGJmalanCea,
Occupenle 1 Controls 01 ConAp. 01 Type Ot Oa(aol 01 GondRlon 1 Ohecurad 01 Driver (uD to Mro) 29
SEQUENCE OF EVENTS Flraf Event 25 Second Evenl Third Evenf FouAh Evanl Moer Harmhil Event (byvenlde) 29
CommerdalTrailer Afleehedto Slele Year Attached to Blala Year EmegencY Emergency
LloenaaPlalelG poworUnil: TrailerUnie VehidaTyoe 1 SIaWa 3
Carrier Name Addreee Clb Sle(a Ztp
USDOTk or MCfe Numberor GrosaVenicle PlacerdN MfltardauaMaledefs
Axlae Welpnl Rallnp Ralerasad7
{f ProFaRy olhar lhan pbjeA Damaged ESlimale of Was ovmer or
ven)crea damaged explsln eLeCTRICAL POLE Dflmege
S6r000,00 lananl nolMed7
Yee
nafaNsme-Las flra idle uffur CompanyOvmerName
ALLIANT ENERGY ALLIANT ENERGY
SVoelorRFD City Slale 2ipCode
DUBU4U2 IA 610D1
ACCIDEN7ENVIRONMENT ROADWAY CHARACTERISTICS WORKZONE RELATE07 SEQUENCE OF EVENTS
Mato! ConUiGuCutg Cln:umaleNOas: No
tocallon of Flra[ HarmNl Event 1 Wealnor Condldan: Envirenmanl 1 Lowlion FIraPNflrmful Evenf of Crean
Mennerol CrasWColtiaial 3 (up to Iwv) 02 Roadway p1 Type (use Codas 112 only) ~ p3
Llehl Condillona - 1 Surface Condilbna 1 Typo o(RoadwayJUnalloN~aoluro 01 Workers presenFT
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NARRATIVE
besorlbe wh@t happened (refer In vehlclee by numher)
MV#1 (A CITY REFUSE TRUCK) WA5 COLLECTING RECYCA9LES ON CARDIFF S7. DRIVER OF #1 WAS OUT OF THE
TRUCK AND HAD ENGAGED THE HOPPER CAUSING THE TRUCKS ENGINE TO REV UP.
MVt21 JUMPED THE SET EMERGENCY BRAKE ANb BEGAN RUNNING bOWN CARDIFF S7. DRIVER OF ~f1 JUMPED BACK
INTO MV#1 1N AN ATTEMPT TO STOP IT. MV #1 RAN INTO MVt~2 WHICH WAS PROPERLY PARKED ON CARDIFF ST. MV#
WAS PUSHED OUT 1NT0 THE SB LANE OF CARDIFF ST. STRIKING MV#3 WHICH WA5 J3EING DRIVEN S8 BY DRIVER ~F3.
MV#i CONTINUED NB ON CARDIFF ST. STRIKING A UTILITY POLE OWNED $Y ALLIANT ENERGY, THE ROLE WA5
SHEARED OFF.
Prlnled A7: Dubuque Pallce Departmehl12177l2009 02:19 PM P0g@ 2 Form b: 01.09.69di6
Dec. 23.~ 2009 ~ 2.09PM NARRATIVE No. 5922-P. 3
Describe whal happened (refer to vehleles by number)
NO INJURIES REPORTED.
ORlear
8ABER9 DAN Bndga No.
60 Time pfficnr Nolmed of Accident
09:1Y Mre. Time Oar Artived AS Scene
09:70 Hra,
Neme olApency
bubu ue POllte bep en{ Dele of Report
12l17f2009 Nvesllgalbn
made alscene9 Yee T.I. S
ReportRe~i By. „
P~ d DaleR vie
~ s!~ d ency50ecI11c OlherTecMicallnveellgellonAgency
PrlntedAk Dubuque Pollce Department 1 2117120 0 9 0 2;19 PM Page 9 Form p: 01.08.66478
~~
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Dec, 23. ~ 2009 ~ 2:08PM
D
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No, 5922 P, 1
rA~aa MAILREDORTSTO: IpWH De erfinenf of Trans 0
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ORiceorbnver8enilcss ~ INVESTIGATING OFFICERS REPORT OF 01.09.68416
P.o, eo« azoa
Dos Molnaa, Iowa 609086204
MOTOR VEhCICLE ACCIDENT
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nlarrenlbn?~
private
Propartyi' ^
Dale arAoeldenl Tlmo of Acelden l Ceurly ~ AGCldenl occurred wUh1n wryorala limi(e o ) L ocation Uteral Deacriplion
~ 1211712008 06:62 Hra . DubuquA-~1 Dubuque-2100 W3R08TelIdCARDIFF87en
~ I(eccldenloccurtedolAStdeo(chyllmlla 9UMIdITST
ahowgenaralvlolnlty, "NIA" ornaaraslclly "N/A"
C On Read, SVeaI,aHlgt+wBy: Allnlerceclionwlh:
A CARDIFF ST W. 3RD ST
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oration /rom a mllspoal or Qe6ne01o Interaeeilan, bridge, er raaroad uoaeing, ueln0 hvo dlslances sno dpscllons K necessary. X~oadtnals: 00681916
p Dlslenae DireeBon Dlatanco Diredien Y•Coordlnale; 04707J2A
N "N1A" "NIA" and "N!A" "NIA" or I /ONttlsd MIOMVgy. Frovlde (iaule
MII:po2t Number Definable Inleresdlon, bridge, or railroad croeaing ( CaralnalJ Travel Direction
"NIA" Or "N(A" NB
Dt~veraName-Leal Flral Middle Suffix HomdCellPhone
WF_LTY JAMES RO6ERT
Address ~ Cl y 31919 ~'ip ~
164x5 OLD NWY ROAD PE O8TA IA ti2088.0000
Dale of BNh OrNers Llcanse Number COaUon Charge Coda i Cllelion Charge 1 ,
1olOaHBBB Bfi472J7J6
Gender Stele CIaa9 Endorsemenla Reelridlone Citation Chef09 Code 2 Chalon Charge 2
Meie IA A LN NONI:
Citation Cherpe Code 9 C1191IOn Charge 3
Alcohol Teel Onrg Test
ON9rt? 7x:1 Retulls GNen? Teal R98UIls; Citellan Charge Coded Chellon Chelgi 4
1 • None 1-Nona
V Sealing Posilion86 InJUry BlalUe B Occupant Prelactioni A'vbng Deployment 6 AlrDeg 8WI~h 8lalue 9 EJadlon 1 E/action PeN 1 Trapped 1
N Trenspofled lo; 7renaponed by.
T Flra{ Middle AuNM Owner Company Name
CI YOFDU9UQUE
oo,~ Addraac City Slala Zip
926 KERPER 6LVb DUBUQUE IA 82044
Insurance Co. Name Insurance p01iny8 L icence Plated 61e1e Yaar
IOWA COMM.ASSURANCE ICAP0300 6 9633 IA 2020
ViN No. Year Make Model Style T ows/ Approxlm ale Coal to
iFVAeXAN71HJ17z34 2001 FRGT TK N O RapairorRepldoe
InilislTravel Vehlcle Speed Polntol MoelDameped Exlenlof Undemider P AualeT
Dlredlon 1 anion 01 Lima 25 IrJOeI tmp9cl 01 Area 02 Dama e 2 Ovemde 1 ^ S6 000,00
Total TfaPfN: VenlCle Cargo Body Vehicle DRref Vieion C onlrlhuting Claumelancee,
Occupanle 1 Controls 01 Con6g. OB type OB Deled 02 Condition ~ Obscured 01 D rher (up to two) 28
SEQUENCE OF EVENTS Final Event 09 Second tllrsnl 07 Third Event 23 Fouts Event 21 MoatWarmful Event (by vehlcla) 21
CommemislTreller Attached to Stale Year Atl9erted to Stale Year Emergency Emergency
Llcanse Plata B Power Unit: Trailer Unil: Vehl:le Type 1 5191ue 3
CanrerName Addross Chy Slate T)D
US 007 # or MC p NGmDefof Oross Vehicle Placard A Warardoue Malenala
Axles WelgntRaling R91eceW7
brNera Neme • Last Firel Middle 8urfbr HomelCell Dhona
Address City Stale Zlp
Date of Birth DMa(e Llc9ne9 Number 01lallCn Charge Code 1 Chaloon Charge 1
Gender Slate Cleea Endoraemonls Realrletlona Ci(adon Charge Code 2 CI1911on Cherga 2
.NOtJE NONE
Acohol Tosl Drug Tael Dn56M Charge Code 0 Ciletlon Cherga 3
Glren7 Teal Reaulls; Divan? Tasl Reaulla: Cilslion Cherga Code 4 Cilatlon Charge 4
U 99a0rg Posttlon In)ury Slalua Oaupanl proleclion AIlD9g Deployment Airbag Switch Status Ejedlon FJacdon Pow Trapped
N
I Trantpodedto: ~ Trenaportedby.
T DSNeme-Leal
6U RaN MOMN S`~0r OwnerCOmD9ryyNama
R ALD
002 911 N pRANDVIEW ~~pprr
~U6000E 1A l9 62001
Insurance Co. Name Insurance PollcytY L kanee Pfale a Slala Year
8 35LgP IA 2003
V(N No. Year Mahe Model 5lyte T aW S Applo«tele Coa110
iGCC519e72816 4 0 6 6 ]OD2 CABVr01el•CMEV N O ReDalrorReplaca
1nI11aITr9vel Veh)clo Speed poinlol MoelDomaBad Erlerllof UndsrYide/ P rNala?
DlreoUon Action ~12 Llmil 2S Inlllallmpsel 08 Area OS Damage 3 Ovenlde 1 ^ $2,000.00
Tolel Tfe16C Vahlale Cnrgo Bony VehIC19 DrNar VI61on C onlr(bu9irg Clfctanelencea,
Occupants 00 Convda 01 Config. 02 type 01 Dated 01 Candilian 6 Obaa.tred ee O river (uD IoNro) 28
SEQUENCE OF EVENT3 Fires Event T1 Second Eyonl Third Event Fouts I;vont Moel Warmtul Er9N (Dyvehlcla) 21
commercial Treller AI~ACtted w Stale Year Attached to Stele Year Emnrgetwy Emergency
UoenSePleteC PowarUhil• TrnilxUnd: Vehlclelype 1 SI91ue 3
CanierName Addreae City 81a1e I1p
US 0078 or MC 8 Numb9rot Gross Vehjde Placard o Mazardoue Malerlela
Ax1os WeiyhtRalinq Reles9ed7
PMted At; Dubuque Pollee Deparlmenll2l17f200a 02:19 PM
Page i Form N:01.OB•68ai6
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