Claim by Cheryl Ludovissy~~~~ ~~~7 .~.~.
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: ~ h-Q r'
2. Address: ~~3~ C,fPSC-e ~~ CZd4e
3. Telephone Number S ~ 3 S" ~y y ~~-iZ
4. Date of Incident: ~ Z~~ S ~ d~
5. Time of Incident: ~ 13U /~- m
6. Location of Incident (Be specific):
_ 3~3~ C r PSc-~~~- R ~~_P _ i n C~ f , ~ e ~~
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 emplo~/yee's na/me.) / // ) ..{~ J
D f ~ ~-~ ~ ! p f ~- ~ ~ L~ ~ ~ g/Q Cx d YI CL 1 !/l /)'1 e- N G{ Y ~ ~ Y`d ~ ) Y'\
8. What were weather conditions like?
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9. Give name and address of any witnesses:
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10. Did police investigate? (If so, give names of officers.)
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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 of damage.) '' JJ - l
~Ltil~ 3~ J !-_~~al ~ ~ ~~~~~ ~iHIS~~~ ~a~1~, I
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
amount paid.)
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15. What amount do you claim from the City of Dubuque? /
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16. 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.)
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18. If the answer to Question 17 is yes, have you received any payment from that
source, and if so, in what amount?
20 ~ ~~ . r~.~~
Dated this ~ °~ day of ~ ~ E 1~~~~ e / ~ .-- ~-
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(Signature)
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(Print Name)
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12/29/2009 at 09:50 AM
18174
Job Number:
RILEY AUTO SALES
Federal ID #:420957277
4455 DODGE STREET
DUBUQUE, IA 52003
(563)588-2326 Fax: (563)583-1327
PRELIMINARY ESTIMATE
Written By: DAVE DEMOSS
Adjuster:
Insured: CHERYL LUDOVISSY
Owner: CHERYL LUDOVISSY
Address: 3535 CRESENT RIDGE
DUBUQUE, IA 52001
Other: (563)580-4542
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Inspect
Location:
Insurance
Company:
Days to Repair
1991 OLDS 88 ROYALS 6-3.8L-FI 4D SED Int:
VIN: 1G3HN54C4MH 331385 Lic: Prod Date: Odometer:
Air Conditioning Tilt Wheel Intermittent Wipers
Tinted Glass Body Side Moldings Dual Mirrors
Clear Coat Paint Power Steering Power Brakes
AM Radio FM Radio Stereo
Search/Seek Cloth Seats Automatic Transmission
Overdrive
--- Full Wheel Covers
--------
N0. OP.
-- ------------------------
DESCRIPTION
-------------------- ----
QTY ------------------
EXT. PRICE LABOR ---------
PAINT
1 ------------
TRUNK LID ---- ------------------ ---------
2* Rpr Lid 4 door 2.0 2.5
3 Add for Clear Coat 1.0
4 REAR BODY
5 0 Repl Finish panel 1 214.99 1.2 1.5
6 Overlap Major Adj. Panel -0.4
7 Add for Clear Coat 0 2
8* Rpr Panel below lid 2.0 1.3
9 Overlap Major Adj. Panel -0.4
10 Add for Clear Coat 0.2
11 REAR LAMPS
12 Repl RT Reflector 1 31.32
13* Repl LKQ RT Tail lamp assy w/back 1 80.00 0.5
up and license lamp
---------------
--------------
Subtotals =_> ---- ------------------
326.31 5.7 ---------
5.9
1
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12/29/2009 at 09:50 AM
18174
Job Number:
PRELIMINARY ESTIMATE
1991 OLDS 88 ROYALE 6-3.8L-FI 4D SED Int:
Parts 326.31
Body Labor 5.7 hrs @ $ 55.00/hr 313.50
Paint Labor 5.9 hrs @ $ 55.00/hr 324.50
Paint Supplies
------------------- 5.9
------- hrs @ $ 35.00/hr 206.50
SUBTOTAL - ------ -- ---------
$ --------
1170.81
Sales Tax
------------------- $
-------- 964.31
------ @
-- 7.0000%
---------- 67.50
-------
GRAND TOTAL
$ 1238.31
ADJUSTMENTS:
Deductible 0.00
----------------------------------------------------
CUSTOMER PAY
INSURANCE PAY
$ 0.00
$ 1238.31
THIS ESTIMATE IS BASED ON A VISUAL INSPECTION AND DOES NOT INCLUDE ADDITIONAL
PARTS OR LABOR THAT MAY BE REQUIRED TO COMPLETE REPAIRS. PART PRICES ARE
CURRENT AND SUBJECT TO INVOICE.
WE FEATURE A LIFETIME WORKMANSHIP LIMITED WARRANTY - SEE OUR WRITTEN WARRANTY
FOR COMPLETE DETAILS.
LIFETIME PAINT PERFORMANCE GUARANTEE USING APPROVED PPG PRODUCTS AND A LIFETIME
GUARANTEE ON OVERALL WORKMANSHIP IS VALID AS LONG AS YOU THE VEHICLE STATED
HEREIN.
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide DO1DB86, CCC Data Date 12/09/2009, 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.
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