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Claim by Arthur Cotton_ _ _ ___ tip ~ ~ ~ ~L;~tM ~. CLAIM AGAINST THE CITY OF DUBUQUE, I©WA 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. 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: (~'~w~--\~w~.~r ~ Q ~\'\-~~r~ 2. Address: ~~L~ \1~ 1\ ~,.~` . -~~ ~ `~A~\'~~.~,~ `~ ~C ~ ~ 1 3. Telephone Number~slC~~~ ~1~ \\ ~~~~ 4. Date of Incident: ~C~\ \~~\ (~ 5. Time of Incident: \ i ~ `. C~ ,1 ~'y~ 6. Location of Incident (Be specific): ~? ~~ ~y tviC `J\V ~.C~ \~ , ~;:;~~^ :~\h `,-=~ ~'<~~CEEC~E'C1 -~c~ ~ca \ ~ -i 4~ZE ~i`c~1 ~ C£ E~ ~ 8. What were weather conditions like? ';1~ ~ ~~. C ~'`~ :~~<`l ; ~, C ~~ ". ~'~ `J C\~"C't yr 9. Give name and address of any witnesses: \~:~'~ \ r~\1~~1 3~1 ~t'~1` `~ ~S \ ~}~l1'~i \~ ~•C~-t -\uC~Cr` C,c,.'rsn r-\ C7t `~ ~~ ~~ ~ 1~ ~ _~ ~ L i~-1 i I I S-{ , # .3 ~~ ~~ ~~ [ /-E 5 ,-1 t,~ 1 [ 10. Did police investigate? (If so, give names of officers.) 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 emolovee's name.) 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). 13. What other damages do you claim, if any? 15. What amount do you claim from the City of Dubuque? 4~ .-1(Y~1 .(~L~ -~' (` i~~~ i ~ C'+1f( l~ ~~ ~`\(i ~ ~.\CS~~~ cl~l (l-~ 16. Why do you claim the City of Dubuque is respon IsIible? .; ('•/~ ~ c ~ ~ ~l h ~ r ' 1. ~% '~ ~c. i V~, .r ,( r"~1 r ~~' ~ -~ h n ~;- 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) `l1 Q 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 ~~~~,t11~1F_~ ~~ , 20 ~ ~_ ,--. ~ ~ - =G c; t_ . - c ~ ~-~~ ~ - (_. ~ c~ ;~ (Signature) `~ ~- ~° _~- ~=~ = .~ ~ r tt~ c,a (Prin Name) 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.) 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.) Date: Estimate ID: Estimate Version: Preliminary Profile ID: BIRD CHEVROLET 3255 UNIVERSITY AVE, DUBUQUE, IA 52001 (563) 583-9121 Fax: (563) 556-4482 Tax ID: 42-0400210 Damage Assessed By: john klotz Deductible: 0.00 Claim Number: 8084 Insured: ARTHUR COTTON Mitchell Service: 912479 Description: 1989 Chevrolet Caprice Brougham LS Body Style: 4D Sed VIN= 1G1BU51E3KR178500 Drive Train: S.OL Inj 8 Cyl AO 12/22/2009 02:14 PM 8084 0 Mitchell Line Item Entry Labor Number Type Operation Line Item Description Part Type/ Part Number Dollar Amount Labor Unite 1 208420 REF BLEND L Fender Outside C 1.0 2 209310 BDY REMOVE/INSTALL L Fender Wheel Opening MIdg Existing 0.2 r 3 219090 BDY REPAIR. L Frt Door Shell Existing 10.0* 4 AUTO REF REFINISH L Frt Door Outside C 2.3 5 220240 BDY REMOVE/REPLACE L Frt Door Rear View Mirror 10113830 GM PART 231.75 0.7 6 220810 BDY REMOVE/REPLACE L Frt Door Outside Handle 20111713 GM PART 92.25 0.2 # 7 221360 GLS REMOVE/R,EPLACE L Frt Door Moveable Glass DD06137GTN 179.15 1.2 8 222140 BDY REPAIR L Rear Door Shell E~sting 8.0* 9 AUTO REF REFINISH L Rear Door Outside C 1.8 10 238021 BDY REMOVE/INSTALL L Rear Daor Trim Panel 0.4 11 223270 BDY REMOVE/INSTALL L Rear Door Outside Handle Ezisting 0.2 #r 12 224380 BDY REMOVE/INSTALL L Rear Otr Door Belt Weatherstrip E~risting 1.2 #r 13 228650 REF BLEND L Quarter Panel Outside C 1.0 14 235590 BDY REMOVE/INSTALL L Combination Lamp Lena Existing 0.4* 15 AUTO REF ADD'L OPR Clear Coat 1.8 16 AUTO ADD'L COST Paint/Materials 276.50 17 AUTO ADD'L COST Hazardous Waste Disposal 6.00 * * -Judgment Item # -Labor Note Applies C -Included in Clear Coat Calc r - CEG R&R Time Used For This Labor Operation ESTIIVIATE RECALL NUMBER: 12!22/2009 14:14:40 8084 Mitchell Data Versioa: OEM: NOV_09 V U1traMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International U1traMate Version: 7.0.014 All Rights Reserved Page 1 of 2 , Date: 12/22/2009 02:14 PM Estimate ID: 8084 Estimate Version- 0 Preliminary ~ • Profile ID: Mitchell Estimate Totals Add'1 Labor Sublet I. Labor Subtotals Unite Rate Amount Amount Totals II. Part Replacement Summary Amount Body 21.3 55.00 0.00 0.00 1,171.50 T Taxable Parts 503.15 Refinish 7.9 65.00 0.00 0.00 434.50 T Sales Tax ~ 7.000% 35.22 Glaea 1.2 58.00 0.00 0.00 69.60 T Total Replacement Parts Amount 538.37 Taxable Labor 1,675.60 Labor Tax @ 7.000 % 117.29 Labor Summary 30.4 1,792.89 III. Additional Coate Amount IV. Adjustments Amount Non-Taaable Costs 282.50 Insurance Deductible 0.00 Total Additional Cceta 282.50 Customer Responsibility 0.00 Paint Material Method: Rates Init Rate = 35.00 , Init Max Hours = 99.9, Addl Rate = 0.00 I. Total Labor: 1,792.89 R. Total Replacement Parts: 538.37 III. Total Additional Costa: 282.50 Gross Total: 2,613.76 IV. Total Adjustments: 0.00 Net Total: 2,613.76 This is a preliminary estimate. Additional chanties to the estimate may be required for the actual repair. ESTIMATE RECALL NUMBER: 12/22/2009 14:14:40 8084 Mitchell Data Version: OEM: NOV 09_V UltraMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International U1traMate Version: 7.0.014 All Rights Reserved Page 2 of 2 Date: 12/22/2009 02:39 PM Estimate ID: E9937 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: ARTHUR/COTTON Address: 320 HILL STREET APT#1, DUBUQUE, IA 52001 Telephone: Home Phone: (708) 441-7808 Mitchell Service: 912479 Description: 1989 Chevrolet Caprice Brougham Body Style: 4D Sed Drive Train: S.OL Inj 8 Cyl AO VIN: 1 G1 BU51 E3KR178500 Line Item Entry Labor Number Type Operation Line Item Description Part Type/ Part Number Dollar Amount Labor Units 1 208600 BDY REPAIR L Fender Panel Existing 1.0* 2 AUTO REF REFINISH L Fender Outside C 2.6 3 209220 BDY REMOVE/REPLACE L Fender Adhesive Moulding ORDER FROM DEALER d18.90 0.2 4 219090 BDY REPAIR L Frt Door Sheli Existing 3.0* 5 AUTO REF REFINISH L Frt Door Outside C 1.9 6 219690 BDY REMOVE/INSTALL L Frt Door Moulding Existing 0.2 r 7 219710 BDY REMOVE/INSTALL R Frt Door Moulding Existing 0.2 r 8 221200 GLS REMOVE/REPLACE L Frt Door Moveable Glass 20106915 GM PART d142.00 1.2 9 222140 BDY REPAIR L Rear Door Shell Existing 6.0* 10 AUTO REF REFINISH L Rear Door Outside C 1.8 11 222510 BDY REMOVE/INSTALL L Rear Door Moulding Existing 0.2 r 12 222580 BDY REMOVEIINSTALL L Rear Lwr Door Moulding Existing 0.2 r 13 228840 BDY REPAIR L Quarter Outer Panel Existing 4.0*# 14 AUTO REF REFINISH L Quarter Panel Outside C 2.0 15 900500 BDS * REMOVE/REPLACE LEFT REAR WHEEL CENTER New 160.00 * 0.2* 16 AUTO REF ADD'L OPR Clear Coat 2.2* 17 933024 GLS ADD'L OPR Broken Glass Cleanup 1,0* 18 AUTO ADD'L COST Paint/Materials 336.00 * 19 AUTO ADD'L COST Hazardous Waste Disposal 3.50 ' * -Judgment Item # -Labor Note Applies d -Discontinued by the Manufacturer C -Included in Clear Coat Calc r - CEG R8~R Time Used For This Labor Operation ESTIMATE RECALL NUMBER: 12/221200914:39:43 E9937 Mitchell Data Version: OEM: NOV_09_V UltraMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International UltraMate Version: 7.0.014 All Rights Reserved Page 1 of 2 Date: 12!22/2009 02:39 PM Estimate ID: E9937 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 15.0 52.00 0.00 0.00 780.00 T Taxable Parts 320 90 Bdy-S 0.2 47.00 0.00 0.00 9.40 T Sales Tax @ 7.000% . 22 46 Refinish 10.5 52.00 0.00 0.00 546.00 T . Glass 2.2 55.00 0.00 0.00 121.00 T Total Replacement Parts Amount 343.36 Taxable Labor 1,456.40 Labor Tax ~ 7.000 % 101.95 Labor Summary 27.9 1,558.35 III. Additional Costs Amount IV. Adjustments Amount Non-Taxable Costs 339.50 Insurance Deductible 0.00 Total Additional Costs 339.50 Customer Responsibility 0.00 Paint Material Method: Rates Init Rate = 32.00 , Init Max Hours = 99.9, Addl Rate = 32.00 I. Total Labor: 1,558.35 II. Total Replacement Parts: 343.36 III. Total Additional Costs: 339.50 Gross Total: 2,241.21 IV. Total Adjustments: 0.00 Net Total: 2,241.21 This is a greliminarv 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: 12!22!2009 14:39:43 E9937 Mitchell Data Version: OEM: NOV_09_V UltraMate is a Trademark of Mitchell International Copyright (C) 1994 - 2009 Mitchell International UltraMate Version: 7.0.014 All Rights Reserved Page 2 of 2 C MARS. MH~L!(CYVKIJ ~~: P Iowa Department of Transportation 5~ a Iowa Department of Trans ortation Law Enforcement Case Number: Office of Driver Services INVESTIGATING OFFICERS REPORT OF 01-09-58707 ~ P 0. Box 9204 Des Moines, Iowa 50306-9204 MOTOR VEHICLE ACCIDENT Legal Private I ntervention?^ Property? ^ Date of Accident Time of Acciden t Count Accid t d ithi t li i L 12119!2009 09:53 Hrs y . Dubuque - 31 en occurre w n corpora e m ts of (city) Dubuque - 2100 Location Literal Description HILL ST ~ If accident occurred outside of city limits C show general vicinity: "NIA" of nearest city "N1A" On Road, Street, or Highway: At Intersection with: A HILL ST "NIA" T Note: Unless accident occurred at an intersection which is com pletely described above use the space below to ive the exact I , g location from a milepost or definable intersection, bridge, or railroad crossing, using two distances and directions 'rf necessary. X-Coordinate: 00690978 ~ Distance Direction Distance Direction Y-Coordinate: 04707353 N 100 Ft 1-N and "NIA" "N1A" of H Divided Highway, Provide Route Milepost Number Definable intersection, bridge, or railroad crossing (Cardinal) Travel Direction "N1A" Or 3RD/HILL ~~N/A~' Driver's Name -Last First Middle Suffuc Home/Cell Phone WELP JEFFREY RICHARD 563 589-4196 x Address City State Zip 3199 i(AUFMANN AVE DUBUQUE IA 52001 Date of Birth Drivers License Number Citation Charge Code 1 Citation Charge 1 706XX0070 9-7-321.268 FAIL TO HAVE CONTROL Gender State Class Endorsements Restrictions Citation Charge Code 2 Citation Charge 2 Male IA A p-N- M Cit ti Ch C d Alcohol Test Drug Test a on arge o e 3 Citation Charge 3 Given? Test Results: Given? Test Results: Citation Charge Code 4 Citation Charge 4 1 -None 1 -None U Seating Position 0l injury Status 5 Occupant Protection2 Airbag Deployment 6 Airbag Switch Status 3 Ejection 1 Ejection Path 1 Trapped 1 N Transported to: Transported by: I REFUSED .r Owners Name -Last First Middle Suffix p y CITY OF DUBUQUE 001 Address City State Zip 50 W13TH DUBUQUE IA 52001 Insurance Co. Name Insurance Policy# L icense Plate # State Year IA COMM ASSURANCE POOL 0 8 5983 IA 1999 VIN No. Year Make Model Style T ow # Approximate Cost to 4RKJNTFA62R836649 2002 NOV BUS BU N O Repair or Replace Initial Travel Vehicle Speed Point of Most Damaged Extent of Underride/ P rivate Direction 1 Action 01 Limit 25 Initial Impact 02 Area 02 Damage 2 Override 1 ^ 5500.00 Total Traffic Vehicle Cargo Body Vehicle Driver Vision C ontributing Circumstances, Occupants 1 ConVols 01 Config. 18 Type 01 Defect 01 Condition 1 Obscured 01 D river (up to two) OS SEQUENCE OF EVENTS First Event 23 Second Event Third Event Fourth Event Most Harmful Event (by vehicle) 23 Commercial Trailer Attached to State Year Attached to State Year Emergency Emergency License Plate # Power Unit: Trailer Unit: Vehicle Type 1 Status 3 Carrier Name Address City State Zip US DOT # or MC # Number of Gross Vehicle Placard # Hazardous Materials Axles Weight Rating Released? Drivers Name -Last First Middle Suffix Home/Cell Phone Address City State Zip Date of Birth Drivers License Number Citation Charge Code 1 Citation Charge 1 Gender State Class Endorsements Restrictions Citation Charge Code 2 Citation Charge 2 NONE NONE Ci i C Alcohol Test Drug Test tat on harge Code 3 Citation Charge 3 Given? Test Results: Given? Test Results: Citation Charge Code 4 CRation Charge 4 V Seating Position Injury Status Occupant Protection Airbag Deployment Airbag Switch Status Ejection Ejection Path Trapped N I Transported to: Transported by. .r Owners Name -Last First Middle Suffer Owner Company Name COTTON ARTHUR J 002 Address City State Zi 12837 S HOYNE ST BLUE ISLAND IL 60426 Insurance Co. Name Insurance Policy # L icense Plate # State Year X 932628 IL 2009 VIN No. Year M e ~ Model Style T ow # Approximate Cost to 1G1BUb1E3KR178600 1989 CAPRICE 4DR N O Repair or Replace Initial Travel Vehicle Speed Point Most Damaged Extent of Underride! P rivate Direction 1 Action 12 Limit 25 Initiallmpact 07 Area 07 Damage 2 Override 1 ^ $800.00 Total Traffic Vehicle Cargo Body Vehicle Driver Vision C ontributing Circumstances, Occupants 0 ConVols 01 Config. 01 Type 01 Defect 01 Condition 8 Obscured 01 D river (up to two) 28 SEQUENCE OF EVENTS First Event 21 Second Event Third Event Fourth Event Most Harmful Event (by vehice) 21 Commercial Trailer Attached to State Year Attached to State Year Emergency Emergency License Plate # Power Unit Trailer Unit: Vehicle Type 1 Status 3 Carrier Name Address City State Zip US DOT # or MC # Number of Gross Vehicle Placard # Hazardous Materials Axles Weight Rating Released? Printed At: Dubuque Police Department 12/19/2009 05:40 PM Page 1 Form #: 01.09-58707 7 t , fj f/ ~ ~p ACCID T E~dVIRO~:'t~~EM1T ROADWAY CHARACTERISTICS WORKZONE RELATED SEQUENCE OF EVENTS Major Contributing Circumstances NO Location of First Harmful Event 1 Weather Conditions Environment 1 Location First Harmful Event of Crash I Manner of CrashlCollisicn 6 (up to tw°) 03 Roadway 01 Type (use codes 112 only) 2g Light Conditions 1 Surface Conditions 1 Type of Roadway JunctioNFeature 01 Workers Present? HILL ST k 3RD ST D I ~ 0 c 0 D ttt I M D 0~° ..airi:~. I HILL ST I NARRATIVE Describe what happened (refer to vehicles by number) VEH #2 WAS LEGALLY PARKED NB ON HILL JUST NORTH OF 3RD ST. VEH #1 WAS NB ON HILL ST WHEN IT SIDESWIPED VEH #2 CAUSING APPROXIMATELY $1300.00 DAMAGE. DRIVER #1 WAS CITED. Officer Badge No. Time Officer Noted of Accident Time Officer Artived At Scene LINDECKER DAVE 75A 09:58 Hrs. 10:02 Hrs. Name of Agency Date of Report Investigation T.I. # Dubuque Police Department 12/19/2009 made at scene? Yes Repo iewed By Date evi~v~d Agency Specfic Other Technical Investigation Agency Printed At Dubuque Police Department 12H9/2009 05:40 PM Page 2 Form #: 01-09-58707