Claim Wardle, TimothyCLAIM 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: Timothy Wardle
2. Address: 757 Fenelon Place
3. Telephone Number: 563 557 0997
4. Date of Incident: 3 15 03
5. Time of Incident: 4:50 - 5:00 A.M.
6. Location of Incident (Be specific):
Right in front of my residence on Fenelon Place
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 had just gotten home from work at 4:45 A.M. Saturday morning and about 5 minutes later I heard a clunking noise but couldn't see much
at that time in the morning. Later that afternoon I noticed the mirror missing - red paint scuffs.
8. What were weather conditions like?
dark
9. Give name and address of any witnesses:
NA
10. Did police investigate? (If so, give names of officers.)
I took the van to the Police Department (Rosethals)
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
NA
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.)
Check answer 7 with scuff marks on the left front light. All damage is done to the drivers side from this incident.
13. What other damages do you claim, if any?
N/A
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.)
$1716.88
15. What amount do you claim from the City of Dubuque?
It was a city ambulance
16. Why do you claim the City of Dubuque is responsible?
N/A
17. Have you made any claim against anyone else for damages as a result of this incident?
(If yes, give name and address.)
N/A
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 17 day of March , 2003.
/s/ Tim Wardle
(Signature)
(Print Name)
(Rev. 1/00 & 7/01)
CLAIM A~AINST TI-II= CITY OF DURUQUE-~tOWA '
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: '--[-~ r~C)~-~
3. TelePhone Number: ( ~'¢~ ~--~ ~'") ~9' ?
4. Date of Incident: ~'~ -- 15 - ~-~ S : '
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
...j
8. wna~ were weather conaitions ~iKeY
9. Give name and address of any witnesses: ~//~-
/
10. Did police ~qvestigate? (If s~give names of office~s.)
11. Was~ anyone inj~ed? (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, i'f any?
14. Have you been compensated for any part or all of your claim by any insurance
company? (If s,o,/g?e name and address of insurance company and amount paid.)
15. What amount do you claim from the City Of Dubuque? ~ /~'~/~,.~ R
/
16. Why do you claim the City of Dubuque is responsible?
17. Have you made any claim against a~nyone else for damages as a result of this incident?
(If yes, give name and address.). 7~/~..
/
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 KY~Y'~ day of
LU
· (Signature)
(Print Hame)
(Rev. 1/00 & 7/01)
03/17/2003
24443
at 11:38 AM
Job Number:
ABRA - DUBUQUE
Federal ID #:420782245
DBA: ANDERSON-WEBER INC
3400 CENTER GROVE DR
DUBUQUE, IA 52003
(563)556-0696 Fax: (563)556-1899
PI~EL IMINARY ESTIMATE
Insured: TIM WARDLE
Owner: TIM W~LRDLE
Address: 9757 FENELON PLACE
DUBUQUE, IA 52001
Business: (563)557-0997
Other: (563)588-5664
InslDect i5~BP~ - DUBUQUE
Location: 3400 CENTER GROVE DR
DUBUQUE, IA 52003
Written by:
Adjuster:
Claim #
Policy #
Deductible:
Date of Loss:
Tl~pe of Loss:
Point of Impact: 11.
Left Front
Business: {563}556-0696
Insurance VICTORIA AUTOMOBILE INSURANCE CO
Company:
Days to Repair
1993 PLYM VOYAGER 4X2 4-2.5L-FI 2D VAN WHITE Int:
YIN: 2P4GH25K6PR125612 Lic: Prod Date: 08/1992 Odometer:
Intermittent Wipers Rear Wiper Tinted Glass
Dual Mirrors Clear Coat Paint Power Steering
Power Brakes Driver Air Bag Bucket Seats
NO. OP. DESCRIPTION QTY EXT. PRICE LAt~OR PAINT
1 FENDER
2 Blnd LT Fender 0 0.00 0.0 1.2
3 FRONT LAMPS
4** Repl A/M LT Lens & housing Voyager 1 104.00 0.5 0.0
& T&C
5 DOOR
6* Rpr LT Door shell 0 0.00 4.0 2.2
7 Add for Clear Coat 0 0.00 0.0 0.9
8* Repl LT Molding Caravan & Voyager 1 30.25 0.3 0.0
9 Repl LT Handle, outside black 1 69.35 0.3 0.0
10'* Repl A/M LT Mirror standard 1 97.00 0.3 0~0
11 SIDE PANEL
12' Rpr LT Side panel w/window 0 0.00 6.0 4.2
standard body
13 Overlap Major Adj. Panel 0 0.00 0.0 -0.4
14 Add for Clear Coat 0 0.00 0.0 0.8
15' Repl LT Molding bright insert 1 122.00 0.3 0.0
standard
16% Subl HAZARDOUS WASTE DISPOSAL 1 4.00 T 0.0 0.0
03/17/2003
24443
at 11:38 AM Job Number:
PREL IMINA~Y ESTIMATE
1993 PLYM VOYAGER 4X2 4-2.5L-FI 2D VA/q WHITE Int:
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
17% Subl TAPE STRIPE 1 18.00 T 0.0 0.0
18% Repl BAG / COVER CA~ 1 4.00 0.2 0.0
Subtotals ==> 448.60 11.9 8.9
Parts 426.60
Body Labor 11.9 hfs @ $ 45.00/hr 535.50
Paint Labor 8.9 hfs @ $ 45.00/hr 400.50
Paint Supplies 8.9 hrs @ $ 28.00/hr 249.20
Sublet/Misc. 22.00
SUBTOTA=L $ 1633.80
Sales Tax $ 1384.60 @ 6.0000% 83.08
GRAND TOTAL $ 1716.88
ADJUSTMENTS:
Deductible 0.00
CUSTOMER PAY $ 0.00
INSURANCE PAY $ 1716.88
WA2~RANTY VALID ONLY WITH ORIGIONAL COPY OF YOUR RECEIPT PAi~TS SUBJECT TO
INVOICE NO GUARANTEE ON RUST ALL PARTS NEW, UNLESS OTHERWISE NOTED
THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF AFTERMARKET CRASH PARTS
SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY
WAP~ULNTIES APPLICABLE TO THESE REPIJ~CEMENT PARTS ARE PROVIDED BY THE
MA~NUFACTURER OR DISTRIBUTOR OF THESE PA/~TS RATHER THA~ THE NL~NUFACTURER OF YOUR
-VEHICLE.
WARRANTY VALID ONLY WITH ORIGIONAL COPY OF RECEIPT. PARTS SUBJECT TO INVOICE.
NO GUA/~ANTEES ON RUST. ALL PA~TS NEW, UNLESS OTHERWISE SPECIFIED.
Estimate based on MOTOR CRASH ESTINZ~TING GUIDE. Unless otherwise noted all items are derived from
the Guide DE3TE91 Database Date 2/2003 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 ~
or Qual 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.
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