Claim by Vicky FullerCLAIM 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 tto o u / as to whether your claim will or will not be paid.
1. Name of Claimant: ± f f 1� I\LJ .l I � r
2. Address: (%(�,J lY / ie i) •e
3. Telephone Number:. 9,23 -1/2 - 1 - j J70 7 /,)r 6
4. Date of Incident: / / /11 ) )(') //\\ _
5. Time of Incident: be��(./ 6 ' / / / ? (,)V — 111 1 /5 — Pm
6. Location of Incident (Be specific): (1ri Z L /'
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.)
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8. What were weather conditions like? � V7�, > /.i
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9. Give name and address of any witnesses:
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.)
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City Clerk's Office
50 W. 13th. St.
Dubuque, IA 52001
01/13/2010 at 10:30 AM Job Number:
30799
Insured: VICKY FULLER
Owner: VICKY FULLER
Address: 2536 QUEEN ST
DUBUQUE, IA 52001
Day: (563)495 -7955
Inspect
Location:
Insurance -
Company:
BRIMEYER AUTO BODY
License #:30799 Federal ID #:421438480
10709 COLLISION DR.
DUBUQUE, IA 52001
(563)583 -4456 Fax: (563)583 -1838
PRELIMINARY ESTIMATE
Written By: KEVIN SMITH
Adjuster:
1995 CHEV G30 4X2 CHEVY VAN 8- 5.7L -FI 2D VAN WHITE Int:
VIN: 1GCGG35K3SF150982 Lic: Prod Date: Odometer:
Intermittent Wipers Tinted Glass Body Side Moldings
Dual Mirrors Clear Coat Paint Power Steering
Power Brakes AM Radio FM Radio
Stereo Search /Seek Anti -Lock Brakes (4)
Driver Air Bag 4 Wheel Disc Brakes Automatic Transmission
Overdrive
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
1 SIDE PANEL
2* Rpr LT Side panel w/o window 8.0 5.0
w /hinged door 125"
3 Add for Clear Coat 2
4 REAR LAMPS
5 ** Repl A/M LT Tail lamp 1 52.00 0.4
6# NO WARRANTY ON REPAIR 1
Subtotals =_> 52.00 8.4 7.0
Parts 52.00
Body Labor 8.4 hrs @ $ 56.00 /hr 470.40
Paint Labor 7.0 hrs @ $ 56.00 /hr 392.00
Paint Supplies 7.0 hrs @ $ 36.00 /hr 252.00
SUBTOTAL
Sales Tax
GRAND TOTAL
ADJUSTMENTS:
Deductible
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 1230.41
1
Claim #
Policy #
Deductible:
Date of Loss:
Type of Loss:
Point of Impact:
Days to Repair
$ 1166.40
$ 914.40 @ 7.0000% 64.01
$ 1230.41
0.00
Damage Assessed By john klotz
Deductible: 0.00
Claim Number: 8140
Insured: VICKY FULLER
Description:
Body Style:
VIN:
OEM/ALT:
Options:
Line Entry Labor
Item Number Type
1 331790 BDY
2 AUTO REF
3 337630 BDY
4 338050 BDY
5 AUTO REF
6 AUTO
7 AUTO
Labor Summary
1995 Chevrolet ChevyVan G30
Van 125" WB
1GCGG35K3SF150982
0
POWER STEERING, ANTI-LOCK BRAKE SYS.
Operation
REPAIR
REFINISH
REMOVE/REPLACE
REMOVE/REPLACE
ADD'L OPR
ADD'L COST
ADD'L COST
* - Judgment Item
# - Labor Note Applies
C - Included in Clear Coat Calc
I. Labor Subtotals Units Rate
Body 15.5 57.00
Refinish 8.3 57.00
Taxable Labor
Labor Tax
23.8
BIRD CHEVROLET
3255 UNIVERSITY AVE, DUBUQUE, IA 52001
(563) 583-9121
Fax: (563) 556-4482
Tax ID: 42-0400210
Mitchell Service: 913485
Line Item
Description
L Quarter Van Side Panel
L Van Side Panel Outside
L Combination Lamp Assembly
L Marker Lamp Assembly
Clear Coat
Paint/Materials
Hazardous Waste Disposal
Estimate Totals
Add'l
Labor Sublet
Amount Amount Totals
0.00 0.00 883.50 T
0.00 0.00 473.10 T
1,356.60
@ 7.000 % 94.96
1,451.56
Drive Train: 5.7L Inj 8 Cy12WD
Search Code: None
ESTIMATE RECALL NUMBER: 01/13/2010 09:44:44 8140
Mitchell Data Version: OEM: DEC_09_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International
UltraMate Version: 7.0.015 All Rights Reserved
Date: 1/13/2010 09:44 AM
Estimate ID: 8140
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Part Type/
Part Number
Existing
5977495 GM PART
5977809 GM PART
II. Part Replacement Summary Amount
Taxable Parts 85.30
Sales Tax @ 7.000% 5.97
Total Replacement Parts Amount
Dollar Labor
Amount Units
15.0 *#
C 5.9
64.08 0.3
2L22 0.2
2.4
290.50 *
6.00 *
Page 1 of 2
91.27
III. Additional Costs
Non-Taxable Costs
Paint Material Method: Rates
Init Rate = 35.00 , Init Max Hours = 99.9, Addl Rate = 0.00
ESTIMATE RECALL NUMBER: 01/13/2010 09:44:44 8140
Mitchell Data Version: OEM: DEC_09_V UltraMate is a Trademark of Mitchell International
Copyright (C) 1994 - 2009 Mitchell International
UltraMate Version: 7.0.015 All Rights Reserved
Date: 1/13/2010 09:44 AM
Estimate ID: 8140
Estimate Version: 0
Preliminary
Profile ID: Mitchell
Amount IV. Adjustments Amount
296.50 Insurance Deductible 0.00
Total Additional Costs 296.50 Customer Responsibility 0.00
I. Total Labor: 1,451.56
II. Total Replacement Parts: 91.27
III. Total Additional Costs: 296.50
Gross Total: 1,839.33
IV. Total Adjustments: 0.00
Net Total: 1,839.33
This is a preliminary estimate.
Additional changes to the estimate may be required for the actual repair.
Page 2 of 2
13. What other damages do you claim, if any? -- / 11
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? ) 0C 7)f (,/ e/"
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16. Why do you claim the City,o Dubu que is responsible? ird cc/o J .
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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?
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Dated this day of , 20
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(Print Name)
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