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Claim Friedman, LoisCLAIM 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 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. 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: Lois Friedman 2. Address: 2645 Windsor 3. Telephone Number: 583 4656 4. Date of Incident: 3 8 03 5. Time of Incident: 3:51 P.M. 6. Location of Incident (Be specific): Corner of Burden & Straus 7. DESCRIBE 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.) I was coming down Burden and the City snow plow didn't stop at stop sign. City employees name is Dale Gross. 8. What were weather conditions like? Cold & Cloudy 9. Give name and address of any witnesses: None 10. Did police investigate? (If so, give names of officers.) Yes - Officer Travis Kramer 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). No 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.) Yes, Right rear from door on back 13. What other damages do you claim, if any? None 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.) No 15. What amount do you claim from the City of Dubuque? $1661.55 16. Why do you claim the City of Dubuque is responsible? Because your City snow plow didn't stop at stop sign. 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 at Dubuque, Iowa this 14 day of March , 2003. /s/ Lois Friedman (Signature) (Print Name) (Rev. 1/00 & 7/01) 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 mail, 50 West 13th Street, Dubuque, Iowa 52001-4864. It will then be referred by the City Council to the appropriate Department for investigation. Once that investigation is completed, a report and reconunendatlon will be submitted to the City Council. You will be provided with a copy of that report and reconunendation. TEE FINAL DECISION ON ALL CLAIMS IS MADE BY TEE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS TEE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WI{ETHER YOUR CLAIM WILL OR WILL NOT BE PAID. of Claimant: s Fr Address: ~&~ ~)~50r Telephone Ntuaber: ~ --~-/g~ 4. Date of Incident: ~ - ~- O_~ 6. Location of incident. (Be specific) DESCRIBE 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.) ~. ~ w~r~ w~ner ~o~t~to~ Ztk~ ~/d 9. Give n~e and address of any witnesses. of off~s.~ 10. Did police investigate? (If so, give names 11. Was anyone injured? (If so, give n~e, address and extent of injuries. ) 12. Was any damage done to property? (If so, describe property and the extent of damage. Attach estimates of damages or describe basis for ascertaining extent of da~nage.) 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 na~e and address of insurance company and amount paid.) _~d~ 15. What amount do you claim from the City of Dubuque? 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: 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what a~ount? Dated at Dubuque, Iowa, this ]~ +~ day of ~¢~ 2005. (Revised January, 2000) (Signature) (Print Name) .... 03/12/2003 at 11:13 AM 30799 Insured: LOIS FRIEDMAN Owner: LOIS PRIEDMAN Address: 2645 WINDSOR AVE DUBUQUE, IA 52001 Day: (563)557-8265 Evening= (563)583-4656 Job Number: BRIME~R AUTO BODY License %:30799 Federal ID %:421438480 10727 JO~ P. KEI~NEDY RD DUBUQUE, IA 52001 (563)583-4456 Fax: (563)583-1838 Adjuster: Days to Repair 1994 CHEV CAV/~LIER ItL 4-2.2L-FI 4D SED GREEN Iht: VIN: 1GtJC5446R7304677 Lic: Prod Date: Tinted Glass Dual Mirrors Clear Coat Paint Power Steering Power Locks A~ti-Lock Brakes (4) Bucket Seats Recline/Lounge Seats 0dometer~ 51364 Custom Interior Power Brakes Cloth Seats NO. OP. DESCRIPTION QTY EXT. PRICE LkBOR PAINT 1 REAR D00R 2 Blnd RT Outer panel sedan 1.1 3 QU~LRTER PANEL 4 Rept RT Quarter panel t 474.10 15.0 3.0 5 Add for Clear Coat 1.2 6% Repl STRIPE TAPE 1 20.00 0.6 7~ RESTORE CORROSION PROTECTION t 10.00 0.2 Subtotals ==> 504.10 15.8 5.3 Parts 504.10 Body Labor 15.8 hfs © $ 44.00/hr 699.20 Paint Labor 5.3 hfs @ $ 44.00/hr 233.20 Paint Supplies 5.3 hfs ~ $ 27.00/hr 143.10 SUBTOTAL $ 1575.60 Sales Tax $ 1432.50 @ 6.0000% 85.95 GRAND TOTAL $ 1661.55 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE1CL88 Database Date 10/2002 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. 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 alte~ate data source. Non-Original Equipment Manufacturer aftermarket parts are described as AM or Qnal Repl Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided from National Auto Glass Specifications, Inc. Pound sign (%) items indicate manual entries. Pathways - A product of CCC Information Services Inc.