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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. Pathways - A product of CCC Information Services Inc.