Claim Takes,Craig J.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 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: Craig J. Takes
2. Address: 13578 Burtons Furnace Rd., Durango, IA 52039
3. Telephone Number: 563 552 1243
4. Date of Incident: 3/5/02
5. Time of Incident: 14:41
6. Location of Incident (Be specific): 1200 block of Dunleith Ct., Dubuque, IA
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.)
A city snow plow driven by Williem Leibfried struck the rear of my 1991 Ford Explorer that was parked on Dunleith Court.
8. What were weather conditions like? Plows were out, lots of snow, but sky was clear
9. Give name and address of any witnesses: Dee Koester, 1275 Dunleith Court, Dubuque
10. Did police investigate? (If so, give names of officers.)
Yes, Officer Fairchild.
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, Damage to the rear and quarter panel of my Ford Explorer. Two extimates for repair are attached.
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?
Repair Costs for the Vehicle
16. Why do you claim the City of Dubuque is responsible?
The vehicle was legally parked on a city street and was truck by a snowplow owned and operated by a city employee.
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 19 day of March , 2003.
/s/ Craig Takes
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
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 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:
2. Address:/~") 0
3. Telephone Number:
4. Date of Incident:
5. Time of Incident:
6. Location of Incident (Be specific):
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.)
8. What were weather conditions like? ~(-~/,]~
9. Give name and addreSs of any witnesses:
10. Did police investigate? (If so, give names of officers.)
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.)
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 name and address of insurance company and amount paid.)
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 amount?
Dated at Dubuque, Iowa this
day of
(Print Ham~)
(Rev. 1/00 & 7/01)
Date: 3/18103 04:23 PM
Estimate ID: 35
Estimate Version: 0
Preliminary
Profile ID: Mitchell
The Body Shop
646 Central Avenue Dubuque, IA 52001
(563) 583-3520
Fax: (563) 557-3177
Damage Assessed By: Cad Robey
Deductible: UNKNOWN
Owner craig takes
Description: 1991 Ford Explorer XLT
Body Style: 4D Ut 112" WB
Mitchell Service: 910621
Drive Train:
4.0L Inj 6 Cyl 4WD
Line Entry Labor
Item Number Type Operation
Line Item
Description
Part Type/ Dollar Labor
Part Number Amount Units
t 024530 BDY REPAIR
2 AUTO REF REFINISH
3 028560 BDY REMOVE/REPLACE
4 AUTO REF ADD'L OPR
5 AUTO ADD'L COST
6 AUTO ADD'L COST
R QUARTER OUTER PANEL
R QUARTER PANEL OUTSIDE
L COMBINATION LAMP ASSEMBLY
CLEAR COAT
PAINT/MATERIALS
HAZARDOUS WASTE DISPOSAL
* - Judgement Item
# - Labor Note Applies
C - Included in Clear Coat Calc
Existing 8.0'#
C 2.8
F3TZ 13405 B 66.30 0.2
1.t
97.50 *
5,00 *
L Labor Subtotals
Body
Refinish
Labor Summary
IlL Additional Costs
Taxable Costs
Add'l
Labor Sublet
Units Rate Amount Amount Totals
8.2 45.00 0.00 0.00 369.00 T
3.9 45.00 0.00 0.00 175.50 T
Taxable Labor 544.50
Labor Tax ~ 6.000 % 32.67
12.1
Sales Tax
Non-Taxable Costs
Total Additional Costs
577.t7
Amount
5.00
6.000% 0.30
97.50
t02.80
il. Part Replacement Summary
Taxable Parts
Sales Tax
Total Replacement Parts Amount
IV, Adjustments
Customer Responsibility
6.000%
Amount
66.30
3.98
70,28
Amount
0.00
ESTIMATE RECALL NUMBER: 3118103 16:21:21 35
UltrsMate is a Trademark of Mitchell International
Mitchell Data Version: MAR_03_A Copyright (C) 1994 - 2002 Mitchell International
UltraMste Version: 4.8,012 All Rights Reserved
Page I
of 2
Date: 3118103 04:23 PM
Estimate iD: 35
Estimate Vemion: 0
Preliminary
Profile ID: Mitchell
I. Total Labor:
II. Total Replacement Parts:
ill. Total Additional Costs:
Gross Total:
577.17
70~8
102.80
750.25
IV. Total Adjustments:
Nc~ Total:
0.00
750.25
This is a preliminary estimate.
Additional chan,qes to the estimate may be required for the actual repair.
WARNING: Accidental air bag deployment is possible. Personal injury may result. Avoid area near steering wheel
and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could
contain an undeployed stage. When disposing of a deployed dual-stage air bag, always treat it as a "live" module.
See appropriate MITCHELL® AIR BAG SERVICE & REPAIR MANUAL, or OEM information.
ESTIMATE RECALL NUMBER: 3118103 16:21:21 35
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: MAR_03_A Copyright (C) 1994 - 2002 Mitchell International
U[treMate Version: 4.8.0'12 All Rights Rese~ed
Page 2
of 2
03/19/2003 at 08:09 AM
30799
Job Number:
BRI}EEYER~JSTO BODY
License ~:30799 Federal ID %:421438480
10727 JOHN F. KENNEDY RD
DUBUQUE, IA 52001
(563)583-4456 Fax: (563)583-1838
Written by: TOM BRIMEYER
Adjuster:
insured: CRAIG TAKES
Owner: CRAIG TAKES
~dress: 13578 BURONS FURNACE RD
DUBUQUE, IA
Day: {563)552-1243
Claim 9
Policy ~
Deductible:
Date of Loss:
T~pe of LOSS:
Point of I~act:
Inspect
Location:
Co,any: Days to Repair
1991 FORD EXPLORER 4X4 6-4.0L-FI 4D UTV Iht:
VIN: 1FMDU34X7MUC03640 Lic: Prod Date: Odometer:
Intermittent Wipers Tinted Glass Dual Mirrors
Clear Coat Paint Power Steering Power Brakes
Anti-Lock Brakes (2) Bucket Seats Deluxe Wheel Covers
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
2* Rpr LT Quarter panel 8.--5 2.5
3 Add for Clear Coat 1.0
4 REAR LAMPS
5 Repl LT Combo lamp assy 1 66.30 0.4
6 STEIPE TAPE
7 Repl LT Stripe tape 4 door body 1 126.72
kit lower kit
Subtotals ==> 193.02 8.9 3.5
Parts 193.02
Body Labor 8.9 hfs @ $ 44.00/hr 391.80
Paint Labor 3.5 hfs @ $ 44.00/hr 154.00
Paint Supplies 3.5 hfs @ $ 27.00/hr 94.50
SUBTOTAL $ 833.12
Sales Tax $ 738.62 @ 6.0000% 44.32
GRAND TOTAL $ 877.44
ADJUSTMENTS:
Deductible 0.00
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 877.44
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from
the Guide DE2MFgl Database Date 1/2003 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
alternate data source. Non-Original Equipment Manufacturer aftermarket parts are described as AM
or Qual Repl Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned
parts are described as Eecon. Recored parts are described as Recore. NAGS Part Numsbers and Prices
are provided from National Auto Glass Specifications, Inc. Pound sign {%) items indicate manual
entries.
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